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Maine Form Center -

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Form

Description

wcb1.pdf Employer's First Report of Occupational Injury or Disease
m1.pdf Diagnostic Medical Report
m2.pdf Request for Independent Medical Examination
wcb2.pdf Wage Statement
wcb2a.pdf Schedule of Dependent(s) and Filing Status Statement
wcb2b.pdf Fringe Benefits Worksheet
wcb2c.pdf Application for Waiver
app_wvr_linstr.pdf Application for Waiver Instructions
wcb3.pdf Memorandum of Payment
wcb4.pdf Discontinuance or Modification of Compensation Pursuant to 39-A M.R.S.A. 205(9)(A)
wcb4a.pdf Consent Between Employer and Employee
wcb6.pdf Certificate Authorizing Release of Benefit Information
wcb7.pdf Certificate Authorizing Release of Unemployment Information
wcb8.pdf Certificate of Discontinuance or Reduction of Compensation Pursuant to 39-A M.R.S.A. 205(9)(B)(2)
wcb9.pdf Notice of Controversy
wcb10.pdf Lump Sum Settlement
wcb11.pdf Statement of Compensation Paid
wcb25.pdf Motion for Award of Fees and Disbursements
wcb120.pdf Petition for Review of Incapacity
wcb121.pdf Employee Petition for Review of Incapacity and Request for Provisional Order
wcb122.pdf Petition to Determine Average Weekly Wage
wcb140.pdf Petition for Award of Compensation
wcb150.pdf Petition for Award of Compensation - Fatal
wcb160.pdf Petition for Award of Compensation - Occupational Disease Law
wcb170.pdf Petition for Restoration
wcb171.pdf Petition for Reinstatement
wcb180.pdf Petition to Determine Extent of Permanent Impairment
wcb190.pdf Petition for Payment of Medical and Related Services
wcb190A.pdf Provider's Petition for Payment of Medical and Related Services
wcb195.pdf Petition to Remedy Discrimination
wcb206.pdf Employee Expense Form
wcb213.pdf Petition for Extension of Benefits Due to Extreme Financial Hardship Pursuant to 39-A M.R.S.A. 213(1)
wcb213A.pdf Petition for Review of Extended Benefits Awarded Due to Extreme Financial Hardship Pursuant to 39-A M.R.S.A. 213(1(B)
wcb220.pdf Limited Certificate Authorizing Written Release of Medical/Health Care Information
wcb230.pdf Employment Status Report
wcb231.pdf Employee's Return to Work Report Pursuant to 39-A M.R.S.A. 308(1)
wcb231A.pdf Employee's Return to Work Report Pursuant to 39-A M.R.S.A. 205(9)(B)
wcb240.pdf Notice of Intent to Appeal
wcb250.pdf Request for Expedited Proceeding
wcb260.pdf Application for Predetermination of Independent Contractor Status to Establish Conclusive Presumption
wcb262.pdf Application for a Certificate of Independent Status
wcb266.pdf Application for Predetermination of Independent Contractor Status to Establish a Rebuttable Presumption
wcb400.pdf Complaint for Penalties Pursuant to 39-A 205(3)
wcb410.pdf Complaint for Penalties Pursuant to 39-A 205(4)
wcb420.pdf Petition for Forfeiture Pursuant to 39-A 324(2)
wcb282.pdf Complaint for Audit
wcb320.pdf Application for Evaluation Employment Rehabilitation Services Pursuant to 39-A M.R.S.A. 217(1)
wcb321.pdf Petition to Determine Entitlement to Rehabilitation Services Pursuant to 39-A M.R.S.A. 217(2)
wcb322.pdf Application for Wage Credit Employment Rehabilitation Fund
wcb90.pdf POSTER - Workers' Compensation Board Notice to Employees