Free 35818_forms - Maine


File Size: 134.5 kB
Pages: 1
Date: January 18, 2002
File Format: PDF
State: Maine
Category: Workers Compensation
Author: Steve_imac
Word Count: 598 Words, 3,892 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.me.us/wcb/petitions/wcb1.pdf

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1. WCB FILE NUMBER (if known):

EMPLOYER'S FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE
REASON FOR REPORT (check all that apply) 2a. I LOST TIME - ONE OR MORE DAYS 3. I LOST EARNINGS BUT NO LOST TIME 6a. I OCCUPATIONAL DISEASE 7a. I CORRECT PRIOR REPORT 2b. WAS EMPLOYEE PAID FOR 1/2 DAY OR MORE ON DAY OF INJURY? 4. I MEDICAL/HEALTH CARE I YES I NO

1a. OSHA 300 CASE NUMBER (if applicable):

5. I FATALITY DATE OF DEATH: _____/_____/_____ MM DD YYYY 6c. DATE OF DIAGNOSIS AS OCCUPATIONALLY RELATED: _____/_____/_____ MM DD YYYY 7c. DATE CORRECTION SENT TO WCB: _____/_____/_____ MM DD YYYY 10. EMPLOYER NAME:

6b. DATE OF LAST EXPOSURE: _____/_____/_____ MM DD YYYY 7b. DATE OF CORRECTION: _____/_____/_____ MM DD YYYY EMPLOYER 9. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN):

8. STATE EMPLOYER UNEMPLOYMENT INSURANCE ACCOUNT NUMBER (UIAN):

11. STREET/P.O. BOX MAILING ADDRESS:

12. CITY:

13. STATE:

14. ZIP:

15. TELEPHONE NUMBER: ( )

16. PRIMARY BUSINESS PERFORMED BY EMPLOYER WHERE INJURY OCCURRED:

17. EMPLOYER LOCATION IF DIFFERENT FROM MAILING ADDRESS:

18. DID INJURY OR EXPOSURE OCCUR ON EMPLOYER'S PREMISES? I YES I NO IF NO, THEN GIVE NAME AND PHYSICAL ADDRESS OF THE EMPLOYER WHERE THE EMPLOYEE WAS INJURED OR EXPOSED:

(check one)

INSURER 20. POLICY NUMBER:

THIRD PARTY ADMINISTRATOR (TPA)

SELF-ADMINISTERED EMPLOYER 21. INSURER FILE NUMBER:

19. INSURANCE/TPA COMPANY NAME:

22. STREET/P.O. BOX MAILING ADDRESS:

23. CITY:

24. STATE:

25. ZIP:

26. TELEPHONE NUMBER: ( )

EMPLOYEE 27. LAST NAME: 28. FIRST NAME: 29. MI: 30. TELEPHONE NUMBER: ( 33. STREET/P.O. BOX MAILING ADDRESS: 34. CITY: ) 36. ZIP: 37. DATE OF BIRTH: _____/_____/_____ MM DD YYYY 38. OCCUPATION/JOB TITLE: 39. DATE OF HIRE: _____/_____/_____ MM DD YYYY 40. WEEKLY WAGE AT TIME OF INJURY: $ 41. DOES EMPLOYEE WORK FOR ANOTHER EMPLOYER? I YES I NO IF YES, GIVE NAME AND ADDRESS: 31. SOCIAL SECURITY NUMBER: 32. GENDER: I MALE I FEMALE

35. STATE:

CLAIM INFORMATION 42. DATE OF INJURY OR ILLNESS: _____/_____/_____ MM DD YYYY DATE EMPLOYER NOTIFIED: _____/_____/_____ MM DD YYYY 48. SPECIFIC INJURY OR ILLNESS (e.g. second degree burn or toxic hepatitis): 43. DATE OF INCAPACITY: _____/_____/_____ MM DD YYYY DATE EMPLOYER NOTIFIED: _____/_____/_____ MM DD YYYY 49. BODY PART(s) AFFECTED (e.g. lower right forearm): 46. TIME OF INJURY (e.g. 1:10 p.m.): 44. TIME EMPLOYEE BEGAN WORK (e.g. 7:30 a.m.): 45. DATE EMPLOYER NOTIFIED INSURER/TPA: _____/_____/_____ MM DD YYYY 47. HAS EMPLOYEE RETURNED TO WORK? I YES I NO IF YES, GIVE DATE: _____/_____/_____ MM DD YYYY 50. ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN THE EVENT OCCURRED (e.g. acetylene torch, metal plate):

51. SPECIFY ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE EVENT OCCURRED (e.g. cutting metal plate for flooring.):

52. HOW INJURY OR ILLNESS OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED OR MADE THE EMPLOYEE ILL. (e.g. worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against hot metal.):

WAS ACTIVITY PART OF NORMAL JOB DUTIES? 53. HOSPITALIZED OVERNIGHT AS INPATIENT? I YES I NO

I YES

I NO 55. HEALTH CARE PROVIDER NAME: 56. MAILING ADDRESS: 57. TELEPHONE NUMBER: ( PREPARER INFORMATION )

54. WAS THE EMPLOYEE TREATED IN AN EMERGENCY ROOM? I YES I NO

58. PREPARER NAME AND TITLE (TYPE OF PRINT):

59. TELEPHONE NUMBER: ( )

60. DATE SENT TO WCB: _____/_____/_____ MM DD YYYY

WCB-1 (1/02) The State of Maine does not discriminate on the basis of disability in admission to, access to, or operation of its programs, services or activities. This material can be made available in alternate formats by contacting your Department ADA Coordinator.

DISTRIBUTION: COPY (1) MAINE WORKERS' COMPENSATION BOARD, 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027, (2) EMPLOYEE, (3) INSURER, (4) EMPLOYER