Maine > Workers Compensation
Discontinuance Or Modification Of Compensation WCB-4 - Maine
| Discontinuance Or Modification Of Compensation Form. This is a Maine form and can be used in Workers Compensation . |
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DISCONTINUANCE OR MODIFICATION OF COMPENSATION PURSUANT TO 39-A M.R.S.A. ยง205(9)(A) 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: PLEASE COMPLETE EITHER THE SECTION FOR DISCONTINUANCE OR MODIFICATION, BUT NOT BOTH. DISCONTINUANCE 18. REASON FOR DISCONTINUANCE: RETURNED TO WORK FOR SAME EMPLOYER REGULAR/FULL DUTY MEDICAL RELEASE BOARD DECISION 19. PERIOD OF INCAPACITY: FROM (DATE): TO: (RETURN DATE): 20. WEEKLY COMPENSATION RATE: RETURNED TO WORK FOR SAME EMPLOYER EARNING AT/ABOVE AVERAGE WEEKLY WAGE OTHER (EXPLAIN) ___________________________________________ 21. AMOUNT PAID: 22. DATE FINAL PAYMENT MAILED: 23. COMMENTS: MODIFICATION 24. REASON FOR MODIFICATION: RETURNED TO WORK FOR SAME EMPLOYER MODIFIED WORK/DUTY BOARD DECISION 25. OLD COMPENSATION RATE: COST OF LIVING ADJUSTMENT (PRE 1993 CLAIMS ONLY) MAX RATE INCREASE 26. NEW COMPENSATION RATE: INCREASED/DECREASED EARNINGS WITH SAME EMPLOYER OTHER (EXPLAIN) ______________________________________ 27. EFFECTIVE DATE OF MODIFICATION: 28. COMMENTS: 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 29. PREPARER NAME (TYPE OR PRINT): 30. TELEPHONE NUMBER: ) 31. DATE MAILED: 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-4 (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com
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