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TABLE OF CONTENTS
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RESOURCES OFFERED BY THE MAINE WORKERS’ COMPENSATION BOARD
MAINE WORKERS’ COMPENSATION BOARD FORMS
EFFECTIVE DATES OF SIGNIFICANT CHANGES
Please note: All Forms are in PDF format. These files requires the free Adobe Reader.
EMPLOYER’S FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE, WCB-1
NOTICE OF WORKERS’ COMPENSATION INSURANCE, WCB-1A
SCHEDULE OF DEPENDENT(S) AND FILING STATUS STATEMENT, WCB-2A
DISCONTINUANCE OR MODIFICATION OF COMPENSATION, WCB-4
CONSENT BETWEEN EMPLOYER AND EMPLOYEE, WCB-4A
CERTIFICATE AUTHORIZING RELEASE OF BENEFIT INFORMATION, WCB-6
(21-DAY) CERTIFICATE OF DISCONTINUANCE OR REDUCTION OF COMPENSATION, WCB-8
NOTICE OF CONTROVERSY (DENIAL), WCB-9
STATEMENT OF COMPENSATION PAID, WCB-11
Instructions for WCB-11 (RTF Format)
LIMITED CERTIFICATE AUTHORIZING WRITTEN RELEASE OF MEDICAL/HEALTH CARE INFORMATION, WCB-220
EMPLOYMENT STATUS REPORT, WCB-230
EMPLOYEE’S RETURN TO WORK REPORT, WCB-231
REQUEST FOR EXPEDITED PROCEEDING, WCB-250
PETITION FOR REVIEW OF INCAPACITY, WCB-120
EMPLOYEE PETITION FOR REVIEW OF INCAPACITYAND REQUEST FOR PROVISIONAL ORDER, WCB-121
PETITION TO DETERMINE AVERAGE WEEKLY WAGE, WCB-122
PETITION FOR AWARD OF COMPENSATION, WCB-140
PETITION FOR AWARD OF COMPENSATION – FATAL, WCB-150
PETITION FOR AWARD OF COMPENSATION – OCCUPATIONAL DISEASE LAW, WCB-160
PETITION FOR RESTORATION, WCB-170
PETITION FOR REINSTATEMENT, WCB-171
PETITION TO DETERMINE EXTENT OF PERMANENT IMPAIRMENT, WCB-180
PETITION FOR PAYMENT OF MEDICAL AND RELATED SERVICES, WCB-190
PROVIDER’S PETITION FOR PAYMENT OF MEDICAL AND RELATED SERVICES, WCB-190A
PETITION TO REMEDY DISCRIMINATION, WCB-195
APPENDIX A: INFORMATION FOR ANNUAL ADJUSTMENTS OF THE WEEKLY COMPENSATION RATE (Word Document)
APPENDIX B: CALCULATING VARYING PARTIAL BENEFITS
APPENDIX C: COST OF LIVING ADJUSTMENTS FOR CLAIMS BETWEEN 10/1/75 AND 6/30/85
APPENDIX D: PERMANENT IMPAIRMENT
APPENDIX E: MAINE WORKERS' COMPENSATION BOARD PENALTIES REFERENCE GUIDE
APPENDIX G: Additional NOC Information (added 4/22/08)