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 19 State Forms found

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APPLICATION FOR WAIVER

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

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)

PETITION FOR REVIEW OF INCAPACITY

 WCB-120 (eff. 1/1/13)

PETITION FOR RESTORATION

 WCB-170 (eff 1/1/13, rev 10/11/23)

PETITION FOR REINSTATEMENT

 WCB-171 (eff 1/1/13, rev 10/11/23)

PETITION TO DETERMINE EXTENT OF PERMANENT IMPAIRMENT

 WCB-180 (eff. 1/1/13)

PETITION FOR PAYMENT OF MEDICAL AND RELATED SERVICES

 WCB-190 (eff. 10/1/15)

PROVIDER'S PETITION FOR PAYMENT OF MEDICAL AND RELATED SERVICES

 WCB-190A (eff. 10/1/15)

PETITION TO REMEDY DISCRIMINATION

 WCB-195 (eff. 1/1/13)

PETITION FOR EXTENSION OF BENEFITS DUE TO EXTREME FINANCIAL HARDSHIP PURSUANT TO 39-A M.R.S.A. §213(1)

 WCB-213 (eff. 1/1/13)

NOTICE OF INTENT TO APPEAL

 WCB-240 (eff. 9/1/18)

REQUEST FOR EXPEDITED PROCEEDING

 WCB-250 (eff. 1/1/13, rev. 12/4/2023)

APPLICATION FOR PREDETERMINATION OF INDEPENDENT CONTRACTOR STATUS TO ESTABLISH CONCLUSIVE PRESUMPTION

 WCB-260 (eff. 1/1/13, rev. 5/8/19)
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