Free DISCONTINUANCE OR MODIFICATION - Maine

DISCONTINUANCE OR MODIFICATION OF COMPENSATION
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:

DISCONTINUANCE
18 REASON FOR DISCONTINUANCE:
RETURNED TO WORK FOR SAME EMPLOYER ' 205 (9) (A) BOARD DECISION 19. PERIOD OF INCAPACITY: FROM (DATE): TO: (RETURN DATE): 20. WEEKLY COMPENSATION RATE: INCREASED EARNINGS ' 205 (9) (A) OTHER (EXPLAIN) ___________________________________________ ___________________________________________________________ 21. AMOUNT PAID: 22. DATE OF FINAL PAYMENT:

MODIFICATION
23. REASON FOR MODIFICATION: RETURNED TO WORK FOR SAME ' 205 (9) (A) INCREASED EARNINGS ' 205 (9) (A OTHER (EXPLAIN) 24. OLD COMPENSATION RATE: DECREASED EARNINGS COST OF LIVING ADJUSTMENTS AVERAGE WEEKLY WAGE ESTABLISHED OTHER ____________________________________ ___________________________________________ 26. EFFECTIVE DATE OF MODIFICATION:

25. NEW COMPENSATION RATE:

27. COMMENTS:

ASSISTANCE IS AVALABLE AT THE BOARD'S REGIONAL OFFICES:
AUGUSTA 24 STONE ST AUGUSTA, ME 04330-5220 287-2168 1-800-400-6854 BANGOR 106 HOGAN RD. BANGOR, ME 04401-5640 941-4550 1-800-400-6856 CARIBOU ONE VAUGHN PLACE 43 HATCH DR, STE 305 CARIBOU, ME 04736 498-6428 1-800-400-6855 PORTLAND 62 ELM ST PORTLAND, ME 04101-6858 822-0840 1-800-400-6858
29. TELEPHONE NUMBER: 30. DATE MAILED:

LEWISTON 36 MOLLISON WAY LEWISTON, ME 04240-5811 753-7700 1-800-400-6857
28. PREPARER NAME AND TITLE (TYPE OR PRINT):

THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIOTAPE. WCB 4 (8/94)