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FORMS EFFECTIVE JANUARY 1, 2013

(all forms are Form-fillable PDF)

 

M-1 Practitioner's Report (PDF)
M-2 Request for Independent Medical Examination (PDF)
WCB-1 Employer's First Report of Occupational Injury or Disease (PDF)
WCB-2 Wage Statement (PDF)
WCB-2A Schedule of Dependent(s) and Filing Status Statement (PDF)
WCB-2B Fringe Benefits Worksheet (PDF)
WCB-2C Application for Waiver (PDF)
  Application for Waiver Instructions (Word 97)
WCB-3 Memorandum of Payment (PDF)
WCB-4 Discontinuance or Modification of Compensation Pursuant to 39-A M.R.S.A. 205(9)(A)(PDF)
WCB-4A Consent Between Employer and Employee (PDF)
WCB-6 Certificate Authorizing Release of Benefit Information (PDF)
WCB-7 Certificate Authorizing Release of Unemployment Information (PDF)
WCB-8 Certificate of Discontinuance or Reduction of Compensation Pursuant to 39-A M.R.S.A. §205(9)(B)(1) (PDF)
WCB-9 Notice of Controversy (PDF)
WCB-10 Lump Sum Settlement (PDF)
WCB-11 Statement of Compensation Paid (PDF)
WCB-25 Motion for Award of Fees and Disbursements (PDF)
WCB-90 Workers' Compensation Board Notice to Employees (POSTER) (PDF)
WCB-90 Notice to Workers (poster effective 06/2010 12/2012) (PDF) **NOTE: Both WCB-90 Posters are required to be posted until 6/30/13**
WCB-120 Petition for Review of Incapacity (PDF)
WCB-121 Employee Petition for Review of Incapacity and Request for Provisional Order (PDF)
WCB-122 Petition to Determine Average Weekly Wage (PDF)
WCB-140 Petition for Award of Compensation (PDF)
WCB-150  Petition for Award of Compensation - Fatal (PDF) 
WCB-160 Petition for Award of Compensation - Occupational Disease Law (PDF) 
WCB-170 Petition for Restoration (PDF)
WCB-171 Petition for Reinstatement (PDF) 
WCB-180 Petition to Determine Extent of Permanent Impairment (PDF)
WCB-190 Petition for Payment of Medical and Related Services (PDF)
WCB-190A Provider's Petition for Payment of Medical and Related Services (PDF)
WCB-195 Petition to Remedy Discrimination (PDF)
WCB-213 Petition for Extension of Benefits Due to Extreme Financial Hardship Pursuant to 39-A M.R.S.A. §213(1) (PDF)
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 Certificate Authorizing Written Release of Medical/Health Care Information (PDF)
WCB-230 Employment Status Report (PDF)
WCB-231 Employee's Return to Work Report Pursuant to 39-A M.R.S.A. 308(1) (PDF)
WCB-231A Employee's Return to Work Report Pursuant to 39-A M.R.S.A. 205(9)(B)(PDF)
WCB-240 Notice of Intent to Appeal (PDF)
WCB-250 Request for Expedited Proceeding (PDF)
WCB-260 Application for Predetermination of Independent Contractor Status to Establish Conclusive Presumption (PDF)
WCB-262

Application for a Certificate of Independent Status (PDF)

WCB-266 Application for Predetermination of Independent Contractor Status to Establish A Rebuttable Presumption (PDF)
WCB-280 Complaint for Penalties Pursuant to 39-A 205(3) (PDF)
WCB-281 Petition for Forfeiture Pursuant to 39-A 324(2) (PDF)
WCB-282 Complaint for Audit (PDF)
WCB-320 Application for Evaluation Employment Rehabilitation Services Pursuant to 39-A M.R.S.A. 217(1) (PDF)
WCB-321 Petition to Determine Entitlement to Rehabilitation Services Pursuant to 39-A M.R.S.A. 217(2) (PDF)
WCB-322 Application for Wage Credit Employment Rehabilitation Fund (PDF)

 

2013 Forms Manual ** updated 03/31/2014 **
2013 Forms Manual Appendices ** updated 05/30/2013 **

 

** Quantities may be reproduced locally or are available through Gossamer Press, Tel (207) 827-9881, Fax: (207) 827-9861