Free WCB 3 - Maine


File Size: 17.8 kB
Pages: 2
Date: August 23, 2001
File Format: PDF
State: Maine
Category: Workers Compensation
Author: Paul J. Fortier
Word Count: 470 Words, 3,634 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.me.us/wcb/petitions/wcb3.pdf

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Preview WCB 3
1. REVISION DATE: _____/_____/_____ MM DD YYYY 3. EMPLOYEE LAST NAME:

MEMORANDUM OF PAYMENT
EMPLOYEE
4. FIRST NAME: 5. MI.:

2. WCB FILE NUMBER (if known):

6. SOCIAL SECURITY NUMBER:

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

8. CITY:

9. STATE:

10. ZIP:

11. HOME PHONE NUMBER: ( )

12. DATE OF INJURY: _____/_____/_____ MM DD YYYY

13. SPECIFIC INJURY OR ILLNESS:

14. BODY PARTS (S) AFFECTED:

EMPLOYER
15. INSURER FILE NUMBER: 16. EMPLOYER NAME: 17. EMPLOYER MAILING ADDRESS AND PHONE NUMBER:

18. INSURER/TPA NAME:

19.INSURER/TPA MAILING ADDRESS:

NOTICE TO EMPLOYEE
20. YOUR EMPLOYER/INSURER IS REQUIRED TO FILE THIS WORKERS' COMPENSATION FORM UPON PAYMENT OF A LOST TIME WORK-RELATED INJURY. PAYMENT IS MADE FOR THE FOLLOWING REASON: A. B. C.

! ! !

YOUR CLAIM IS ACCEPTED. THIS IS A VOLUNTARY PAYMENT PENDING INVESTIGATION. THIS IS A MANDATORY PAYMENT BECAUSE A NOTICE OF CONTROVERSY WAS NOT TIMELY FILED PURSUANT TO RULE 1.1. PERIOD COVERED BY MANDATORY PAYMENT: FROM (DATE) _____/_____/_____ THROUGH (DATE) ______/_____/_____ MM DD YYYY MM DD YYYY AMOUNT PAID $ ________

21. TYPE OF PAYMENT: A. C.

! !

WEEKLY COMPENSATION PERMANENT IMPAIRMENT

B. AMOUNT PAID $ _____________ D.

! !

SPECIFIC LOSS _________________WEEKS

AMOUNT PAID $ ___________

OTHER (EXPLAIN) ________________________________________________________

22 A. IS THERE ANY INDICATION THAT THE INJURY IS PERMANENT?

!

YES

!

NO %

B. IF THE ANSWER IS YES, WHAT IS THE PERMANENT IMPAIRMENT RATING?

!

NOT YET AVAILABLE

23. DATE OF INCAPACITY:

_____/_____/_____ MM DD YYYY

24. DATE CHECK MAILED: _____/_____/_____ MM DD YYYY

25. AVERAGE WEEKLY WAGE: $

26. CURRENT WEEKLY COMPENSATION RATE:

!

TOTAL ! PARTIAL

$

DATE EMPLOYER NOTIFIED: _____/_____/_____ MM DD YYYY

27. DOES EMPLOYEE WORK FOR ANOTHER EMPLOYER? IF YES, GIVE NAME:

!

YES ! NO

28. FIRST DAY OF COMPENSABILITY AFTER WAITING PERIOD IS MET: _____/_____/_____ MM DD YYYY

29. IS THIS AN APPORTIONMENT CLAIM? ! YES

! NO

IF YES, ANSWER THE FOLLOWING:

OTHER DATE(S) OF INJURY INVOLVED: ______________________________________________________________________________________________________ OTHER CARRIER(S) INVOLVED: ____________________________________________________________________________________________________________ WHO IS THE "LEAD" CARRIER? _____________________________________________________________________________________________________________ EXPLAIN THE TERMS OF THE APPORTIONMENT: _____________________________________________________________________________________________

30. COMMENTS:

ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS' COMPENSATION BOARD'S REGIONAL OFFICES
AUGUSTA 24 STONE ST. AUGUSTA, ME 04330-5220 (207)287-2308 (Voice) (207)287-6119 (TTY) 1-800-400-6854 (Voice) BANGOR 106 HOGAN ROAD BANGOR, ME 04401-5638 (207)941-4550 1-800-400-6856 CARIBOU 43 HATCH DRIVE CARIBOU, ME 04736-2347 (207)498-6428 1-800-400-6855 LEWISTON 140 CANAL ST. LEWISTON, ME 04240-7777 (207)783-5490 1-800-400-6857 PORTLAND 62 ELM ST. PORTLAND, ME 04101-3061 (207)822-0840 1-800-400-6858

31. CLAIM HANDLER NAME (TYPE OR PRINT):

32. TELEPHONE NUMBER: ( ) TOLL FREE NUMBER: ( )

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

E-MAIL ADDRESS:
WCB-3 (10/98) 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's ADA Coordinator. DISTRIBUTION: COPY (1) MAINE WORKERS' COMPENSATION BOARD, 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027, (2) EMPLOYEE, (3) INSURER, (4) EMPLOYER