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 64 State Forms found

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EMPLOYER’S FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE

 WCB-1 (eff. 1/1/13)

REQUEST FOR INDEPENDENT MEDICAL EXAMINATION

 WCB M-2 (eff. 1/1/13, rev. 10/15/15)

WAGE STATEMENT

 WCB-2 (effective 04/01/2025)

SCHEDULE OF DEPENDENT(S) AND FILING STATUS STATEMENT

 WCB-2A (effective 09/27/2023)

FRINGE BENEFITS WORKSHEET

 WCB-2B (eff. 9/1/2020)

APPLICATION FOR WAIVER

 WCB-2C (eff. 1/1/13)

MEMORANDUM OF PAYMENT

 WCB-3 (effective 04/01/2025)

MODIFICATION OF COMPENSATION

 WCB-4M (effective 04/01/2025)

CONSENT BETWEEN EMPLOYER AND EMPLOYEE

 WCB-4A (eff. 9/1/20, rev. 12/4/23)

CERTIFICATE AUTHORIZING RELEASE OF BENEFIT INFORMATION

 WCB-6 (effective 9/1/2020)

CERTIFICATE AUTHORIZING RELEASE OF UNEMPLOYMENT INFORMATION

 WCB-7 (eff. 9/1/2020, rev. 7/5/2022)

CERTIFICATE OF DISCONTINUANCE OR REDUCTION OF COMPENSATION

 WCB-8 Effective 04/01/2025

NOTICE OF CONTROVERSY

 WCB-9 (eff. 9/1/2020, rev. 12/4/2023)

LUMP SUM SETTLEMENT

 WCB-10 (effective 9/1/2020)

STATEMENT OF COMPENSATION PAID

 WCB-11A Effective 04/01/2025
Disclaimer: These forms may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.
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