The Maryland Workers Compensation Claimants Questionnaire (Uninsured Employer) is a document used by the State of Maryland to determine the eligibility of an individual to receive workers’ compensation benefits from an uninsured employer. The questionnaire consists of three parts: Part A, Part B, and Part C. Part A is the Maryland Workers Compensation Claimants Information Form, which is used to collect information about the individual claimant, such as name, date of birth, Social Security number, address, and employer information. Part B is the Maryland Workers Compensation Claimants Statement of Injury Form, which is used to collect information about the claimant’s injury, such as the date of the injury, the body part injured, the nature of the injury, and the medical treatment required. Part C is the Maryland Workers Compensation Claimants Employer Information Form, which is used to collect information about the uninsured employer, such as name, address, contact information, and the type of business. The purpose of this questionnaire is to determine the eligibility of the claimant to receive workers’ compensation benefits from an uninsured employer.