| 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 02/20/2013 **
2013 Forms Manual Appendices |
