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FORMS
Most forms are fillable PDF files.
| Form # | Description |
|---|---|
| M-1 | Diagnostic Medical Report (Word or Fillable PDF) (Updated 11-14-23) |
| 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) (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-2B | Fringe 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-6 | Certificate 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-25 | Motion 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-121 | Employee Petition for Review of Incapacity and Request for Provisional Order |
| WCB-122 | Petition 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-170 | Petition for Restoration (Updated 10-11-23) |
| WCB-171 | Petition 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-195 | Petition to Remedy Discrimination |
| WCB-205 | Work Search Record |
| WCB-206 | Employee Expense Form (Updated 12-4-23) |
| WCB-211 | Petition to Terminate Benefit Entitlement |
| WCB-213 | Petition for Extension of Benefits Due to Extreme Financial Hardship Pursuant to 39-A M.R.S.A. §213(1) |
| WCB-213A | Petition 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-230 | Employment Status Report |
| WCB-231 | Employee's Return to Work Report Pursuant to 39-A M.R.S.A. §308(1) |
| WCB-231A | Employee's Return to Work Report Pursuant to 39-A M.R.S.A. §205(9)(B) |
| WCB-240 | Notice 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-262 | Application for a Certificate of Independent Status- Wood Harvester |
| WCB-267 | Independent Contractor Statement - Online fillable. (Printable version available here) |
| WCB-282 | Complaint 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-322 | Application 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) | |
| In Person Hearing Motion (Word) and Memo (Word) |
If you have questions, please contact Debi Hutchins.