Free CERTIFICATE OF DISCONTINUANCE OR REDUCTION - Maine

CERTIFICATE OF DISCONTINUANCE OR REDUCTION 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:

NOTICE TO EMPLOYEE
YOUR WEEKLY COMPENSATION BENEFITS WILL BE DISCONTINUED OR REDUCED 21 DAYS FROM THE DATE THIS CERTIFICATE WAS MAILED BASED ON THE ATTACHED INFORMATION. IF YOU DISAGREE WITH THIS ACTION, YOU ARE ENTITLED TO FILE A PETITION FOR REVIEW AND TO REQUEST THE PROVISIONAL REINSTATEMENT OF YOUR BENEFITS. YOUR PETITION AND REQUEST SHOULD BE MAILED TO THE ABOVE WORKERS' COMPENSATION BOARD ADDRESS. 18 REASON FOR DISCONTINUANCE:

DISCONTINUANCE
19. PERIOD OF INCAPACITY: FROM (DATE): TO (EFFECTIVE DATE OF DISCONTINUANCE): 20. WEEKLY COMPENSATION RATE: 21. COMPENSATION PAYMENT TO DATE OF CERTIFICATE: 22. COMPENSATION TO BE PAID FOR 21 DAY PERIOD:

REDUCTION
23. OLD COMPENSATION RATE: 24. NEW COMPENSATION RATE: 25. EFFECTIVE DATE OF REDUCTION: 26. 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
28. TELEPHONE NUMBER: 29. DATE MAILED:

LEWISTON 36 MOLLISON WAY LEWISTON, ME 04240-5811 753-7700 1-800-400-6857
27. 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: 1-888-8019087 OR TTY (877) 832-5525 WCB -8 (8/94) DISTRIBUTION: COPY (1) WORKERS' COMPENSATION BOARD, (2) EMPLOYEE, (3) INSURER, (4) EMPLOYER