Fill and Sign the Employee Claim Form Instructions Maryland Workers Compensation

- 1 - BEFORE THE ___________ WORKERS’ COMPENSATION COMMISSION CLAIMANT, V. WCC NO. EMPLOYER, CARRIER ) )))))))) CLAIMANT'S FIRST SET OF REQUEST FOR PRODUCTION Comes now the claimant, _______________, pursuant to the rules of the ______________ Workers' Compensation Commission, and requests the Employer/Carrier to produce and perm it the inspection and copying of the following documents within thirty (30) days after receipt t hereof at the office of counsel for Claimant located at ________________________________________________________. The term "documents" includes, but is not limited to, all handwritten, typed, printed and photocopies matter, and drafts, duplicates, carbon copies or any other copy thereof, in the possession, custody or control of the Carrier or the counsel for the Employer and Carrier i ncluding without limiting the generality of the definition all letters, correspondence, memoranda, notes, reports, statements, paraphrases of statements, drawings, tape recordings, graphs and charts, printouts and computations, work papers, studies, agreements, contracts, and records of te lephone calls in the possession, control or custody of the Employer or Carrier or its att orney. The manner of inspection shall be personal inspection including the copying and photographing by or on behalf of the Claimant the following mentioned documents, and other tangible things, not privileged. 1. REQUEST NO. Please produce a copy of the entire claim file of _______________concerning ________________________. -2- 2. REQUEST NO. Please produce a copy of all medical, hospital, drug or doctor's bill incurred by Claimant in connection with the injuries and/or medical condition for w hich claim is made herein, which have not previously been provided to claimant. 3. REQUEST NO. Please produce a copy of all medical reports in your possessi on concerning Claimant, __________________. 4. REQUEST NO. Please produce a copy of all documents filed by _________________with the _____________ Workers' Compensation Commission in connection with the injuries sustained by _________________while an employee at ___________________. 5. REQUEST NO. All insurance agreements or policies under which any person or e ntity carrying on an insurance business may be liable, to satisfy part or all of a judgm ent that may be rendered in this action or to indemnify or reimburse for payments made to satisfy the judgment. 6. REQUEST NO. All photographs or videotapes that Employer/Carrier has of the Claimant. 7. REQUEST NO. Copies of all statements made by Claimant concerning the subject matter of this lawsuit, including any written statement signed or otherwise adopted or approved by the Claimant hereto and any stenographic, mechanical, electrical or other type of re cording or any transcription thereof made by the Claimant hereto and contemporaneously recorded. 8. REQUEST NO All experts' reports that have been prepared in connection wit h this lawsuit or the incident giving rise to this lawsuit, if the expert is expe cted to or may testify in this cause as an expert. If any such expert has not prepared a report, request is hereby ma de that one be prepared and furnished to Claimant's attorney. 9. REQUEST NO. A true and correct copy of the Claimant's personnel file wi th Defendant's insured. -3- 10. REQUEST NO. All documents comprising or relating in any way to personnel records, including job applications, job descriptions, and job evaluations. 11. REQUEST NO. All wage and/or payroll records of the Claimant, including all pay stubs, time cards, benefit payments, wages, or the like. Claimant requests that Defendants produce the above mentioned documents and records at the office of the Claimant's attorney, __________________________________________for inspection and copying at or before the close of the business on or before the ______ day afte r this Request for Production is served on the Employer/Carrier.