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MAINE WORKERS' COMPENSATION BOARD FORMS REFERENCE GUIDE
| BOARD FORM | FORMS | SPECIFIC STATUTES | SPECIFIC REGULATIONS | GENERAL STATUTES | GENERAL REGULATIONS | FILING REQUIREMENTS |
|---|---|---|---|---|---|---|
| WCB-1 | First Report of Injury | §303 | 1.7 8.13 8.16 |
§152(10) §153(4) §357(1) §360(1)(2) |
15.9(2) 15.10(2) |
Filed by employer within 7 days from notice/knowledge of incapacity. |
| WCB-2 | Wage Statement | §153(4) §205(8) §303 |
1.7 | §152(10) §153(4) §357(1) §360(1)(2) |
15.9(2) 15.10(2) |
Filed by employer within 30 days of notice or knowledge of a claim. |
| WCB-2a | Schedule of Dependents and Filing Status Statement | 1.7 8.9 |
§102(1) §152(10) §153(4) §205(8) §303 §357 §360(1)(2) |
15.9(2) 15.10(2) |
Filed by employer within 30 days of notice or knowledge of a claim. |
|
| WCB-2c | Application for Waiver | §102(11)(A)(4)(5) | ||||
| WCB-3 | Memorandum of Payment | §153 (1) (B) §205(7)(A)(B)(C)(D) |
1.1 (A) (B) 1.1 (3) 1.7 8.12 |
§152 (10) §153 (4) §357 (1) §360 (1) (2) |
15.9 (2) 15.10 (2) |
Should be filed by carrier within 14 days from employer's notice/knowledge of incapacity, and must be date stamped by WCB within 3 mail days thereafter. |
| WCB-4 | Discontinuance or Modification of Compensation | 1.7 8.11 8.12 |
§152 (10) §153 (4) §205 (9)(A) §357 (1) §360 (1) (2) |
15.9 15.1 |
||
| WCB-4a | Consent between Employer and Employee | 8.18 | ||||
| WCB-5 | Certificate Authorizing Release of Benefits Information from the Social Security Administration | §221 (5) | §360 (1)(2) | 15.9 (2) 15.10 (2) |
||
| WCB-6 | Certificate Authorizing teh Release of Benefits Information | §221 (5) | §360 (1)(2) | 15.9 (2) 15.10 (2) |
||
| WCB-8 | Certificate of Discontinuance or Reduction of Compensation | §205 (9) (B) (1) | 1.7 | §152 (10) §153 (4) §357 (1) §360 (1) (2) |
15.9 (2) 15.10 (2) |
|
| WCB-9 | Notice of Controversy | §313 (1) | 1.1 (C ) 1.7 8.2 8.12 |
§152 (10) §153 (4) §357 (1) §360 (1) (2) |
15.9 (2) 15.10 (2) |
Filed by Carrier within 14 days
from notice/knowledge of incapacity, and must be date stamped by the WCB within 3 mail days thereafter. |
| WCB-10 | Lump Sum Settlement | 1.7 | §352 (1) §153 (4) §357 (1) §360 (1) (2) |
12.6 (1) (2) 15.9 (2) 15.10 (2) |
||
| WCB-11 | Statement of Compensation Paid | 1.7 8.1 8.12 |
§152 (10) §153 (4) §357 (1) §360 (1) (2) |
15.9 (2) 15.10 (2) |
Filed by the carrier within 6 months from the date of injury when indemnity benefits are paid and on the injury date(s) anniversary subsequent to that. Final report filed when no further benefits are anticipate. |
|
| WCB-12 | Employer's Supplemental Report | 1.7 8.16 (1) (2) |
§152 (10) §153 (4) §303 §357 (1) §360 (1) (2) |
15.9 (2) 15.10 (2) |
Filed by the employer within 7 days of the employee's return to work when a MOP or NOC is not required. |
|
| WCB-220 | Limited Certificate Authorizing Written Release of Medical/Health Care Information | 12.18 (1) | §208 (1) |
12.18 (2) | ||
| WCB-221 | Certificate Authorizing Release of Information | §152(2) | 16.1 16.2 16.3 |
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| WCB-230 | Employment Status Report | §308(2) | 1.8 | |||
| WCB-231 | Employee's Return to Work Report | §308(1) | 1.7 8.17 |
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| WCB-250 | Request for Expedited Hearing | 1.9 | §205(9)(E) §315 |
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| 1AWC | Proof of Coverage | 1.10 | §152 (10) §153 (4) §357 (1) §360 (1) (2) §403 (1) |
15.7 (2) 15.9 (2) 15.10 (2) |
Filed within 14 days of the start date of new and renewal policies. |