Form 5020 for Maryland 2025

Form 5020 for Maryland: What You Should Know

In the event that you use this form for legal purposes, or disclose information about an accident, injury or illness you know or suspect to have been caused by your employee you shall include the following statement or statements on your employment record. By using this form you certify that you are authorized to disclose the following information: 1. Name of your employee and address of the premises. 2. Name, address, date, and occupation of your employee and all the following: a. Personal information (name, address, birthdate, date and place of birth, Social Security number, etc.) b. Injuries to your employee. 3. Injuries to others. 4. How and where the accident occurred. SUMMARY OF INFORMATION.  1. Name of employee (Full name: first, surname, middle name). 2. Occupation (Full name, middle name, and title, if applicable). 3. Age when last injury occurred (if applicable) (or date of injury if none). 4. Injury type (if any). 5. Occupational category of employee injured (if any). 6. Description of injury (if any). SUMMARY OF THE INFORMATION.  1. _______________________ Incidental Injury _______________________ (Full name: first, surname and middle name). 2. _______________________ Occupation _______________________ (Full name, middle name, and title, if applicable). 3. _______________________ Injury _______________________ (Full name, middle [2 letters][3 letters][4 letters][5 letters][6 letters][7 letters][8 letters], address of injury, description of injuries, and occupational category of employee injured (if any)). 4. _______________________ Company _______________________ (Full name). 5. _______________________ Occupation _______________________ (Full name, middle name, and title, if applicable). 6. _______________________ Company _______________________ (Full name). 7. _______________________ Occupational category _______________________ (Full name, middle name, and title, if applicable). 8. _______________________ ___________________/ ___________________ Occupation ____________________, (Full name, middle [2 letters][3 letters][4 letters][5 letters][6 letters][7 letters][8 letters], and company). 9. _______________________ ____________/ ____________ Occupation ____________, (Full name, middle name, and title, if applicable). 10.

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