NOTICE OF CONTROVERSY
THIS IS A DENIAL OF YOUR BENEFITS	1.	WCB FILE # (if known):
DN5	
EMPLOYEE	
2.  EMPLOYEE LAST NAME:
DN43	3.  FIRST NAME:
DN44	4. MI:
DN45	5. EMPLOYEE ID:

TYPE: DN270     #:          DN(42/152/153/154/156)                            	
6.  STREET/P.O. BOX MAILING ADDRESS:
NA – DN46 
(will print all NA boxes with data from FROI)	7. CITY:
NA – DN48	8. STATE:
NA – DN49	9.  ZIP:
NA – DN50	10.  HOME PHONE #:
NA - 51	
11. DATE OF INJURY:
      DN31             _____/_____/_____  
                                  	12.  SPECIFIC INJURY OR ILLNESS:
NA-DN35	1.	BODY PART(S) AFFECTED:
NA – DN36	
EMPLOYER	
14.  INSURER/CLAIM ADMIN FILE #:
DN15	15.  EMPLOYER NAME:
NA – DN18	16.  EMPLOYER MAILING ADDRESS AND PHONE #:
NA – DN168, 165, 170, 167, and 159	
17.  INSURER/CLAIM ADMIN NAME AND ADDRESS:
DN188, NA – DN10, 12, 13, and 14	18.  INSURER/CLAIM ADMIN FEIN:
DN187	
19.	NOTICE TO EMPLOYEE
YOUR EMPLOYER/INSURER IS DENYING YOUR WORKERS’ COMPENSATION CLAIM OR PART OF IT. THE REASON FOR THE DENIAL IS CHECKED BELOW.
IF YOU DISAGREE WITH THIS DENIAL, CONTACT A CLAIMS RESOLUTION SPECIALIST AT THE NEAREST REGIONAL OFFICE LISTED BELOW.	
19a.			
FULL DENIAL REASON 

DN198

FULL DENIAL EFFECTIVE DATE   ___/DN199_/_____

*NOTE: Reasons identified in boxes 19a or 19b will not preclude a party from raising additional issues at a later date.	19b.						
PARTIAL DENIAL REASON

DN294	
	20a.

                   DATE OF INITIAL  INCAPACITY   ___/DN56/___   
                   CURRENT DATE OF INCAPACITY  ___/DN144/___	
	20b.

DATE EMPLOYER NOTIFIED    _____/DN281_/_____  
         	
21.                                                                                                             COMMENTS:

DN197	
22. IF THIS DENIAL NOTICE IS NOT TIMELY PURSUANT TO RULE 1.1, the employee must be paid total benefits, with credit for earnings and other statutory offsets, from the date of incapacity in accordance with 39-A M.R.S.A. § 205(2) and in compliance with 39-A M.R.S.A. § 204.  The requirement for payment of benefits under this subsection automatically ceases upon the filing of a Notice of Controversy and the payment of any accrued benefits. Payment under Rule 1.1 requires filing of a Memorandum of Payment.	
ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS’ COMPENSATION BOARD’S REGIONAL OFFICES

                                 AUGUSTA	                          BANGOR	                       CARIBOU	                   LEWISTON	                  PORTLAND
                              24 STONE ST.	SUITE 2           106 HOGAN ROAD                       43 HATCH DRIVE SUITE 110    36 MOLLISON WAY 	    	62 ELM ST.	
                              AUGUSTA, ME   	      BANGOR, ME	                       CARIBOU, ME	                   LEWISTON, ME	                 PORTLAND, ME
                                04330-5220	                         04401-5638	                        04736-2347	                    04240-5811		04101-3061
                          (207)287-2308 (Voice)	     (207)941-4550	                       (207)498-6428	                    (207)753-7700	                 (207)822-0840
                          1-800-400-6854 (Voice)                1-800-400-6856	                      1-800-400-6855	                   1-800-400-6857	                1-800-400-6858  
                         TTY 1-877-832-5525	
23. NAME (TYPE OR PRINT):  
DN140

E-MAIL ADDRESS:
DN138

	24.  TELEPHONE #:
   (               )
DN137	25.  DATE SENT TO WCB:

	_____/DN100_/_____	  

26. DATE RCVD AT THE  WCB (WCB use only):

_____/_____/_____	

WCB-9 (1/12/06) 	The State of Maine does not discriminate on the basis of disability in admission to, access to, or operation of its programs, services, or activities. This form is available in alternative format. For further assistance, contact the Maine Workers' Compensation Board, ADA Coordinator, telephone: 1-888-801-9087 or TTY (877) 832-5525.
DISTRIBUTION: COPY (1) EMPLOYEE, (2) EMPLOYER