Forms

The 121^st Maine Legislature mandated that the Workers' Compensation Board take steps to introduce electronic data interchange (EDI) in form filing. As of January 1, 2005, all First Report of Injury forms were required to be filed through EDI. As of July 1, 2006, all Notice of Controversy Forms were required to be filed through EDI. In addition, as of the publication of this edition of the GUIDE it is expected that as of January 1, 2007, all Memorandum of Payment forms will be required to be filed through EDI. The number of forms required to be filed in this manner is expected to grow.

As of the publication of this edition of the GUIDE, the Board will permit electronic filing through either the IAIABC Claims Release 3 or through the Workers' Compensation Board proprietary format. Questions regarding these formats should be directed to the Agency Technology Officer at (207) 287-3818.

The Workers' Compensation Board has made forms available on the web. Most are available electronically at http://www.maine.gov/wcb/departments/board.htm. The Board has issued a Petitions and Forms Manual which contains copies of all of the forms and instructions on how to complete them. This is available on the world wide web at http://www.maine.gov/wcb/departments/mae/mae/training.htm Also available on the web at http://www.maine.gov/wcb/departments/mae/Audit/reference_guide.htm is the Board Forms Reference Guide. Please refer to the Petitions and Forms Manual or the Board Forms Reference Guide for thorough instructions. Some forms have been changed since the Manual was last updated as noted below, but the Manual remains a good guide. Below you will find a summary of the forms you are likely to use on a daily basis and a brief explanation of completing and filing requirements.

WCB-1 FIRST REPORT. Within seven days of the employer receiving notice or having knowledge of an injury which requires the services of a health provider, a First Report must be filled out and distributed to the employee, the insurer, and the employer's file. The First Report does not need to be filed with the Board, however, unless there is lost time. If the injury causes the loss of one or more days of work, a copy must be filed with the Workers' Compensation Board (39-A M.R.S.A. §303). This form was revised in November of 2001 in order to allow applicable employers to comply with the Board and OSHA requirements (i.e., OSHA -301 form) by using only one form. The new form (WCB-1(1/02)) must be used as of May 1, 2002. It is mandatory that at least one box from 2(a) through 7(a) be check-marked and that boxes 10, 27, 28, 42, and 43 be completed.

WCB-2 WAGE STATEMENT. Within 30 days after the employer receives notice or has knowledge of a claim for compensation, a Wage Statement must be filed with the Board.

WCB-2A SCHEDULE OF DEPENDENTS AND FILING STATUS STATEMENT. The Wage Statement must be accompanied by the Schedule of Dependents and Filing Status Statement.

WCB-3 MEMORANDUM OF PAYMENT. A Memorandum of Payment must be filed within 14 days of knowledge of a claim for incapacity benefits in order to report the start of weekly compensation benefits, or benefits for impairment (see MEMORANDUMS OF PAYMENT). Failure to file a timely MOP will result in penalties (see PENALTIES). Further, if the mandatory box on the MOP is left blank, the MOP will be returned to the party and the time for filing will continue to run until a properly completed MOP is filed with the Board. Boxes 3, 4, 12, 16, 18 and 20 are mandatory on the MOP.

WCB-4 DISCONTINUANCE OR MODIFICATION OF COMPENSATION. This form is used when benefits are stopped or reduced for one of the following reasons: the employee has returned to work with the same employer; there has been a hearing officer decision; the employee's earnings with the same employer have changed; or a modification is needed because of coordination of benefits (e.g., social security offset). It is not used for discontinuances or reductions under 39-A M.R.S.A. §205(9)(B).

WCB-8 CERTIFICATE OF DISCONTINUANCE OR REDUCTION OF COMPENSATION. This form is filed by certified mail with the Board and the employee to give "21-day notice" that compensation will be reduced pursuant to 39-A M.R.S.A. §205(9)(B)(1) (see REDUCING OR TERMINATING BENEFITS).

WCB-9 NOTICE OF CONTROVERSY. This form, commonly referred to as a "NOC," is filed to report the controverting of a claim for weekly compensation or other benefits. The "reasons for dispute" box should contain a brief summary, such as "condition not related to employment." The NOC form was revised in January 2006; the new form (WCB-9)(1/12/06) must be used as of July 1, 2006. The new form allows for more space for the explanation of whether a partial or a full denial of the claim is being made. Failure to file a timely NOC will result in penalties (see PENALTIES and DISPUTING CLAIMS). Further, if a mandatory box is left blank, the NOC will be returned to the party and the time for filing will continue to run until a properly completed NOC is filed with the Board. Boxes 2, 3, 11, 15, and 17 are mandatory on the NOC.

WCB-10 LUMP SUM SETTLEMENT. This form is used, together with an appropriate release and affidavit, for settlements to be approved by the Board. This form was also revised in March 1998; the new form (WCB-10)(3/98)) must be used as of August 1, 1998.

WCB-11 STATEMENT OF COMPENSATION PAID. This form must be filed on lost time cases six months from the date of initial indemnity payment, and then every year on the anniversary date of the injury thereafter, or as a final report if the case is closed to report the cumulative amount paid in indemnity benefits. This form was revised, and the new form (WCB-11)(3/98)) must be used as of August 1, 1998.

WCB-230 EMPLOYMENT STATUS REPORT. An employee receiving benefits is required to file this report to show earnings from a different employer. Ordinarily, it will follow the filing of WCB-231 (see below). The employer should fill in the top portion of the form, and mail it to the employee immediately upon the initiation of lost time benefits. The employee is required to complete the report 90 days after the date of injury and every 90 days thereafter. This form should be sent out and on a diary every 90 days.

WCB-231 EMPLOYEE'S RETURN TO WORK REPORT. The employee is required to complete and return this form within seven days of his or her return to work with a new employer. The top of this form should be filled out by the employer sent to the employee immediately upon the initiation of lost time benefits.

WCB-250 REQUEST FOR EXPEDITED PROCEEDING. A provisional order or an expedited proceeding is requested with this form.