FORMS

Most forms are fillable PDF files.

Form # Description
M-1 Diagnostic Medical Report (Word or Fillable PDF) (Updated 11-14-23)
M-2Request for Independent Medical Examination
WCB-1Employer's First Report of Occupational Injury or Disease
WCB-2 Wage Statement (Updated 9-3-20) (PDF)
WCB-2 Wage Statement (Updated 9-3-20) (Excel .xlsm Version Released 7-5-23)
WCB-2A Schedule of Dependent(s) and Filing Status Statement (Updated 9-27-23)
WCB-2BFringe Benefits Worksheet (Updated 9-3-20)
WCB-2C Application for Waiver
Application for Waiver Instructions (PDF)
WCB-3 Memorandum of Payment (Updated 12-4-23)
WCB-4A Consent Between Employer and Employee (Updated 12-4-23)
WCB-4D Discontinuance of Compensation - this revised form will be required on 9-1-2020 (Updated 12-4-23)
WCB-4M Modification of Compensation - this revised form will be required on 9-1-2020 (Updated 12-4-23)
WCB-6Certificate Authorizing Release of Benefit Information (Updated 9-23-20)
WCB-7 Certificate Authorizing Release of Unemployment Information (Updated 7-5-22)
WCB-8 Certificate of Discontinuance or Reduction of Compensation Pursuant to 39-A M.R.S.A. §205(9)(B)(1) (Updated 12-4-23)
WCB-9 Notice of Controversy (Updated 12-4-23)
WCB-10 Lump Sum Settlement (Updated 9-14-20) *Note: you may need to download the form to use the electronic signature feature.
WCB-11 Statement of Compensation Paid (Updated 12-4-23)
WCB-25Motion for Award of Fees and Disbursements
WCB-90 Workers' Compensation Board Notice to Employees (POSTER) (Revised 12-4-23)
WCB-120 Petition for Review of Incapacity
WCB-121Employee Petition for Review of Incapacity and Request for Provisional Order
WCB-122Petition to Determine Average Weekly Wage
WCB-140 Petition for Award of Compensation (Updated 10-11-23)
WCB-150 Petition for Award of Compensation - Fatal
WCB-160 Petition for Award of Compensation - Occupational Disease Law
WCB-170Petition for Restoration (Updated 10-11-23)
WCB-171Petition for Reinstatement (Updated 10-11-23)
WCB-180 Petition to Determine Extent of Permanent Impairment
WCB-190 Petition for Payment of Medical and Related Services
WCB-190A Provider's Petition for Payment of Medical and Related Services
WCB-195Petition to Remedy Discrimination
WCB-205Work Search Record
WCB-206 Employee Expense Form (Updated 12-4-23)
WCB-211Petition to Terminate Benefit Entitlement
WCB-213Petition for Extension of Benefits Due to Extreme Financial Hardship Pursuant to 39-A M.R.S.A. §213(1)
WCB-213APetition for Review of Extended Benefits Awarded Due to Extreme Financial Hardship Pursuant to 39-A M.R.S.A. §213(1)(B)
WCB-220 Limited Release of Medical/Health Care Information (Updated 10-23-23)
WCB-220-A Limited Release of Medical/Health Care Information Related to Psychological Matters (Updated 10-23-23)
WCB-220-B Limited Release of Medical/Health Care Information Related to Substance Abuse (Updated 10-23-23)
WCB-220-C Limited Release of Medical/Health Care Information Related to HIV/AIDS and Sexually Transmitted Diseases (updated 10-23-23)
WCB-220-R Revocation of Limited Release of Medical/Health Care Information (Updated 10-23-23)
WCB-230Employment Status Report
WCB-231Employee's Return to Work Report Pursuant to 39-A M.R.S.A. §308(1)
WCB-231AEmployee's Return to Work Report Pursuant to 39-A M.R.S.A. §205(9)(B)
WCB-240Notice of Intent to Appeal
WCB-250 Request for Expedited Proceeding (Updated 12-4-23)
WCB-260 Application for Predetermination of Independent Contractor Status to Establish Conclusive Presumption
WCB-262Application for a Certificate of Independent Status- Wood Harvester
WCB-267 Independent Contractor Statement - Online fillable. (Printable version available here)
WCB-282Complaint for Audit
WCB-320 Application for Evaluation Employment Rehabilitation Services Pursuant to 39-A M.R.S.A. §217(1) (Updated 10-11-23)
WCB-322Application for Wage Credit Employment Rehabilitation Fund
WCB-400Complaint for Penalties Pursuant to 39-A §205(3)
WCB-410Complaint for Penalties Pursuant to 39-A §205(4)
WCB-420Petition for Forfeiture Pursuant to 39-A §324(2)
Joint Scheduling Memorandum (Word or Fillable PDF)
In Person Hearing Motion (Word) and Memo (Word)

If you have questions, please contact Debi Hutchins.