Maine > Workers Compensation
Certificate Of Discontinuance Or Reduction Of Compensation WCB-8 - Maine
| Certificate Of Discontinuance Or Reduction Of Compensation Form. This is a Maine form and can be used in Workers Compensation . |
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CERTIFICATE OF DISCONTINUANCE OR REDUCTION OF COMPENSATION PURSUANT TO 39-A M.R.S.A. §205(9)(B)(2) STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 1. INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER (last 4 digits): 7. WCB FILE NUMBER: XXX-XX2. 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: 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 MAY FILE A PETITION FOR REVIEW AND REQUEST REINSTATEMENT OF YOUR BENEFITS PENDING HEARING, UNDER 39-A M.R.S.A. §205(9)(C). YOUR PETITION AND REQUEST (ON FORM WCB-121) MUST BE MAILED TO THE WORKERS' COMPENSATION BOARD ADDRESS ABOVE. 18. REASON FOR DISCONTINUANCE OR REDUCTION (MUST ATTACH SUPPORTING DOCUMENTATION): NOTICE TO EMPLOYEE DISCONTINUANCE 19. PERIOD OF INCAPACITY: FROM (DATE): TO (EFFECTIVE DATE OF DISCONTINUANCE): 20. WEEKLY COMPENSATION RATE: 21. COMPENSATION PAID 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: AUGUSTA 24 STONE ST, STE 102 AUGUSTA, ME 04330-5220 (207) 287-2308 1-800-400-6854 ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS' COMPENSATION BOARD'S REGIONAL OFFICES BANGOR 106 HOGAN RD BANGOR, ME 04401-5638 (207) 941-4550 1-800-400-6856 CARIBOU ONE VAUGHN PL 43 HATCH DR, STE 110 CARIBOU, ME 04736 (207) 498-6428 1-800-400-6855 LEWISTON 36 MOLLISON WAY LEWISTON, ME 04240-7777 (207) 753-7700 1-800-400-6857 PORTLAND 62 ELM ST PORTLAND, ME 04101-3061 (207) 822-0840 1-800-400-6858 26. PREPARER NAME (TYPE OR PRINT): 27. TELEPHONE NUMBER: ( ) 28. DATE MAILED (MUST MATCH POSTMARK): E-MAIL ADDRESS: TOLL-FREE NUMBER: ( ) _____/_____/_____ MM DD YYYY The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers' Compensation Board. Telephone: 1-888-801-9087 or TTY Maine Relay 711. WCB-8 (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com
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