Fiscal Department

SB 119 address submital form

Recently enacted Senate Bill 119 becomes EFFECTIVE JUNE 1, 2014.

WORKERS’ COMPENSATION –SUBSEQUENT INJURY FUND – BILLING ADDRESS NOTIFICATION

Requiring, on or before July 1, 2014, and on or before July 1 each year thereafter, an employer or its insurer that is liable for payment of specified Subsequent Injury Fund assessments to notify the Subsequent Injury Fund of the current billing address to which notices of payment shall be sent; requiring the employer or its insurer to notify the Subsequent Injury Fund of any change of billing address within 30 days of the change of address; etc.

To comply please complete the following SIF Billing Notification Form and press the Email Form button to send it to: sharris@nullmdsif.state.md.us

If you would rather fax it you can fill out the form and then PRINT IT and send to 410-527-4021

EMPLOYER NAME:
INSURER NAME: *  
BILLING ADDRESS: *  
TELEPHONE NUMBER: *  
CONTACT NAME: *  
CONTACT EMAIL:
DATE:
 
Required *
Status: Not Submitted