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)