Free RELEASE OF BENEFIT INFORMATION - Maine


File Size: 10.0 kB
Pages: 1
Date: August 23, 2001
File Format: PDF
State: Maine
Category: Workers Compensation
Author: Melinda J Porter
Word Count: 314 Words, 2,231 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.me.us/wcb/petitions/wcb6.pdf

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CERTIFICATE AUTHORIZING RELEASE OF BENEFIT INFORMATION
STATE OF MAINE WORKERS' COMPENSATION BOARD STATION 27, AUGUSTA, MAINE 04333-0027
PART 1 EMPLOYER/INSURER COMPLETES BOXES 1 THROUGH 17 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:

PART II EMPLOYEE COMPLETES THIS SECTION:
I _______________________________________________, AUTHORIZE THE ABOVE-NAMED EMPLOYER/INSURER TO OBTAIN WRITTEN INFORMATION INDICATING THE NATURE AND AMOUNT OF BENEFITS I RECEIVED OR AM RECEIVING FROM THE FOLLOWING:

SOCIAL SECURITY ADMINISTRATION EMPLOYEE BENEFITS PLAN(S)

NAME OF EMPLOYEE BENEFIT PLAN ADDRESS - NUMBER AND STREET CITY, STATE, ZIP

I UNDERSTAND THAT THE ABOVE-NAMED EMPLOYER/INSURER IS ENTITLED TO RECEIVE THIS SOCIAL SECURITY OLD AGE INSURANCE OR EMPLOYEE BENEFIT PLAN INFORMATION PURSUANT TO 39-A M.R.S.A. SECTION 221 (5) AND THAT MY FAILURE TO COMPLETE THIS CERTIFICATE MAY RESULT IN THE DISCONTINUANCE OF MY WEEKLY WORKERS' COMPENSATION BENEFITS. THIS CERTIFICATE OF RELEASE SHALL BE VALID FOR ONE YEAR FROM THE DATE OF MY SIGNATURE.

EMPLOYEE SIGNATURE

DATE

PART III SOCIAL SECURITY ADMINISTRATION OR EMPLOYEE BENEFIT PLAN COMPLETES THIS SECTION

TO: SOCIAL SECURITY ADMINISTRATION OR EMPLOYEE BENEFIT PLAN

THE ABOVE-NAMED EMPLOYEE AUTHORIZED THE RELEASE OF BENEFIT INFORMATION PURSUANT TO 39-A M.R.S.A. SECTION 221 (5). PLEASE PROVIDE THE FOLLOWING INFORMATION TO THE ABOVE-NAMED EMPLOYER/INSUER: 1. 2. 3. 4. EFFECTIVE DATE OF ELIGIBILITY: CURRENT GROSS MONTHLY AMOUNT: PERCENTAGE OF EMPLOYEE BENEFIT PLAN PAID BY EMPLOYER (IF APPLICABLE): ARE BENEFITS FROM THIS EMPLOYEE BENEFIT PLAN SUBJECT TO REDUCTION BASED ON RECEIPT OF WORKERS' COMPENSATION BENEFITS? IF YES, EXPLAIN BELOW UNDER COMMENTS. COMMENTS:

5.

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

7. TELEPHONE NUMBER:

8. DATE MAILED:

THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIOTAPE. WCB 6 (3/97)