Maine > Workers Compensation
Fringe Benefits Worksheet WCB-2B - Maine
| Fringe Benefits Worksheet Form. This is a Maine form and can be used in Workers Compensation . |
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STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 ,1685(5 ),/( 180%(5 (03/2<(5 1$0( 62&,$/ 6(&85,7< 180%(5 ODVW GLJLWV :&% ),/( 180%(5 ),567 1$0( 0, FRINGE BENEFITS WORKSHEET ;;;;; (03/2<(( /$67 1$0( (03/2<(5 0$,/,1* $''5(66 $1' 3+21( 180%(5 (03/2<(( $''5(66180%(5 $1' 675((7 ,1685(5 1$0( &,7< 67$7( =,3 +20( 3+21( ,1685(5 0$,/,1* $''5(66 '$7( 2) ,1-85< '(6&5,37,21 2) ,1-85< PROVIDE THE COST OF THE FRINGE BENEFIT PAID BY THE EMPLOYER AS OF THE EMPLOYEE'S DATE OF INJURY IF THE EMPLOYEE WAS RECEIVING THE BENEFIT ON HIS/HER DATE OF INJURY (SEE RULE CHAPTER 1(5)(1)). NOTE: THE AMOUNTS REPORTED ARE SUBJECT TO VERIFICATION BY THE EMPLOYEE AND HIS/HER REPRESENTATIVE AND DOCUMENTATION MUST BE PROVIDED UPON REQUEST. Fringe Benefit +HDOWK %HQHILWV LQF LQVXUDQFH 'HQWDO ,QVXUDQFH 'LVDELOLW\ ,QVXUDQFH LQF VKRUW DQG ORQJ WHUP . /LIH ,QVXUDQFH (GXFDWLRQ7UDLQLQJ 3HQVLRQ 2WKHU SOHDVH OLVW 2WKHU SOHDVH OLVW Link/Embed this Document |
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