Free DISCONTINUANCE OR MODIFICATION - Maine

CONSENT BETWEEN EMPLOYER AND EMPLOYEE
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.

TERMS OF CONSENT:

18A. DATE OF INCAPACITY:

18B. AVERAGE WEEKLY WAGE:

18C. CURRENT WEEKLY COMPENSATION
RATE: TOTAL PARTIAL

18D. DOES EMPLOYEE WORK FOR ANOTHER
EMPLOYER? IF YES, GIVE NAME(S): YES NO

18E. NEW COMPENSATION RATE:

18F. EFFECTIVE DATE OF REDUCTION:

18G. EFFECTIVE DATE OF DISCONTINUANCE:

18H. AMOUNT PAID:

NOTICE TO EMPLOYEE (Please read and initial)
19. BEFORE YOU SIGN THIS FORM, YOU SHALL CALL THE W ORKERS' COMPENSATION BOARD'S OFFICES TO FIND OUT WHAT RIGHTS YOU RIGHTS YOU HAVE IF YOU SIGN THIS FORM. A LIST OF THE BOARD'S REGIONAL OFFICES IS SHOWN AT THE BOTTOM OF THIS PAGE. EMPLOYEE INITIALS: _____________________________________

NOTICE TO EMPLOYER
THIS FORM SHALL NOT BE USED FOR CASES WHEN AN ORDER, AWARD OF COMPENSATION OR A COMPENSATION SCHEME WAS ENTERED UNDER SECTION 205 (9)(B)(2).

CONSENT
20. WE AGREE TO THE TERMS LISTED IN BOX 18 ABOVE. WE UNDERSTAND THAT THIS IS NOT A FINAL SETTLEMENT. SIGNING THIS CONSENT FORM CREATES A PAYMENT WITHOUT PREJUDICE DOES NOT CREATE A PAYMENT SCHEME, AND DOES NOT PREVENT EITHER PARTY FROM REOPENING THE CLAIM W ITHIN CERTAIN TIME LIMITS. THIS FORM MUST BE SIGNED BY THE EMPLOYEE AND THE EMPLOYER/INSURER OR BY A DULY AUTHORIZED REPRESENTATIVE.

EMPLOYEE OR AUTHORIZED REPRESENTATIVE SIGNATURE

DATE

EMPLOYER/INSURER OR AUTHORIZED REPRESENTATIVE SIGNATURE

DATE

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
22. TELEPHONE NUMBER: 23. DATE MAILED:

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

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 FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS' COMPENSATION BOARD, ADA COORDINATOR, TELEPHONE: 1-888-801-9087 OR TTY (877) 832-5525 WCB 4A (8/94)