FORMS

(all forms are Form-fillable PDF)

*If you have any questions or comments about the forms effective on 9/1/2020, please contact Debbie Morton.

Form # Description
M-1 Diagnostic Medical Report (Word or Fillable PDF)
M-2 Request for Independent Medical Examination
WCB-1 Employer's First Report of Occupational Injury or Disease
WCB-2 Wage Statement (Updated 9-3-20)
WCB-2A Schedule of Dependent(s) and Filing Status Statement (Updated 9-3-20)
WCB-2B Fringe Benefits Worksheet (Updated 9-3-20)
WCB-2C Application for Waiver
Application for Waiver Instructions (PDF)
WCB-3 Memorandum of Payment (Updated 9-17-20)
WCB-4A Consent Between Employer and Employee (Updated 9-4-20)
WCB-4D Discontinuance of Compensation - this revised form will be required on 9-1-2020 (Updated 9-18-20)
WCB-4M Modification of Compensation - this revised form will be required on 9-1-2020 (Updated 9-21-20)
WCB-6 Certificate Authorizing Release of Benefit Information (Updated 9-23-20)
WCB-7 Certificate Authorizing Release of Unemployment Information (Updated 9-4-20)
WCB-8 Certificate of Discontinuance or Reduction of Compensation Pursuant to 39-A M.R.S.A. §205(9)(B)(1) (Updated 9-23-20)
WCB-9 Notice of Controversy (Updated 9-23-20)
WCB-10 Lump Sum Settlement (Updated 9-14-20)
WCB-11 Statement of Compensation Paid (Updated 9-15-2020)
WCB-25Motion for Award of Fees and Disbursements
WCB-90 Workers' Compensation Board Notice to Employees (POSTER) (Revised 1/2020)
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-140Petition for Award of Compensation
WCB-150 Petition for Award of Compensation - Fatal
WCB-160 Petition for Award of Compensation - Occupational Disease Law
WCB-170Petition for Restoration
WCB-171Petition for Reinstatement
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-205 Work Search Record
WCB-206Employee Expense Form
WCB-211 Petition 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-220Limited Release of Medical/Health Care Information
WCB-220-A Limited Release of Medical/Health Care Information Related to Psychological Matters
WCB-220-B Limited Release of Medical/Health Care Information Related to Substance Abuse
WCB-220-C Limited Release of Medical/Health Care Information Related to HIV/AIDS and Sexually Transmitted Diseases
WCB-220-R Revocation of Limited Release of Medical/Health Care Information
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-250Request for Expedited Proceeding
WCB-260 Application for Predetermination of Independent Contractor Status to Establish Conclusive Presumption
WCB-262Application for a Certificate of Independent Status- Wood Harvester
WCB-266 Application for Predetermination of Independent Contractor Status to Establish A Rebuttable Presumption
WCB-282Complaint for Audit
WCB-320Application for Evaluation Employment Rehabilitation Services Pursuant to 39-A M.R.S.A. §217(1)
WCB-322Application for Wage Credit Employment Rehabilitation Fund
WCB-400 Complaint for Penalties Pursuant to 39-A §205(3)
WCB-410 Complaint for Penalties Pursuant to 39-A §205(4)
WCB-420 Petition for Forfeiture Pursuant to 39-A §324(2)
Joint Scheduling Memorandum (Word or Fillable PDF)