Free Wage Statement - Maine


File Size: 9.8 kB
Pages: 2
Date: August 23, 2001
File Format: PDF
State: Maine
Category: Workers Compensation
Author: Melinda J Porter
Word Count: 182 Words, 1,176 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.me.us/wcb/petitions/wcb2.pdf

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Preview Wage Statement
WAGE STATEMENT
STATE OF MAINE WORKERS' COMPENSATION BOARD STATION 27, AUGUSTA, MAINE 04333-0027
1. INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER 7. WCB FILE NUMBER:

2. EMPLOYER NAME:

8. EMPLOYEE LAST NAME:

9. FIRST NAME:

10. M.I.:

3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER:

11. ADDRESS-NUMBER AND STREET:

4. INSURER NAME:

12. CITY:

13. STATE:

14. ZIP:

15. HOME PHONE:

5. INSURER MAILING ADDRESS:

16. DATE OF INJURY:

17. DESCRIPTION OF INJURY:

18. DOES EMPLOYEE WORK FOR ANOTHER EMPLOYER? IF YES, THE EMPLOYER SHALL SUBMIT A WAGE STATEMENT FROM EACH ADDITIONAL EMPLOYER. 20.

YES NO

19. DOES EMPLOYEE RECEIVE FRINGE BENEFITS THAT MAY STOP WHILE ON WORKERS; COMPENSATION?.

YES NO

WEEK 52 IS THE WEEK BEFORE THE INJURY
WEEK ENDING GROSS EARNINGS

WK 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

WK 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

WK 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
21. TOTAL EARNINGS 22. GROSS AVERAGE WEEKLY WAGE $ $

23. PREPARER NAME AND TITLE (TYPE OR PRINT):

24. TELEPHONE NUMBER:

25. DATE MAILED:

THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIOTAPE. WCB 2 (8/94)