Maine > Workers Compensation
Employees Return To Work Report WCB-231 - Maine
| Employees Return To Work Report Form. This is a Maine form and can be used in Workers Compensation . |
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EMPLOYEE'S RETURN TO WORK REPORT STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 PART I (COMPLETED BY EMPLOYER/INSURER) ,1685(5 ),/( 180%(5 (03/2<(5 1$0( 62&,$/ 6(&85,7< 180%(5 ODVW GLJLWV :&% ),/( 180%(5 ),567 1$0( 0, ;;;;; (03/2<(( /$67 1$0( (03/2<(5 0$,/,1* $''5(66 $1' 3+21( 180%(5 $''5(66180%(5 $1' 675((7 ,1685(5 1$0( &,7< 67$7( =,3 +20( 3+21( ,1685(5 0$,/,1* $''5(66 '$7( 2) ,1-85< '(6&5,37,21 2) ,1-85< NOTICE TO EMPLOYER/INSURER 7+( (03/2<(5,1685(5 6+$// 6(1' 7+( (03/2<(( 6 5(7851 72 :25. 5(3257 72 7+( (03/2<(( :+(1 ),/,1* 7+( 0(025$1'80 2) 3$<0(17 38568$17 72 0$5 &+ NOTICE TO EMPLOYEE ,) <28 5(7851 72 :25. :,7+ $ 1(: (03/2<(5 &203/(7( %2;(6 $1' $1' ),/( &23,(6 2) 7+,6 5(3257 :,7+ 7+( %2$5' $1' <285 35(9,286 (03/2<(5 $7 7+( $''5(66(6 /,67(' $%29( :,,7+,1 '$<6 38568$17 72 $ 056$ )$,/85( 72 &203/(7( $1' 5(7851 7+,6 5(3257 0$< $))(&7 <285 :25.(56 &203(16$7,21 ,1'(01,7< %(1(),76 PART II (COMPLETED BY THE EMPLOYEE) &203/(7( 7+( )2//2:,1* ,1)250$7,21 86( 5(9(56( 6,'( ,) 1(&(66$5< $ 1(: (03/2<(5 1$0( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 7(/(3+21( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB $''5(66 BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB &,7< BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 67$7( BBBBBBBBBBBBB =,3 BBBBBBBBBBBBBBBBBBBBBBBBBBBBB % & '$7( 2) +,5( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB $77$&+ 9(5,),&$7,21 2) ,1&20( 25 /,67 $17,&,3$7(' ,1&20( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB ' &200(176 , +(5(%< &(57,)< 7+$7 7+( ,1)250$7,21 &217$,1(' ,1 7+,6 5(3257 ,6 7587+)8/ $1' $&&85$7( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB (03/2<(( 6,*1$785( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB '$7( 7KH 6WDWH RI 0DLQH SURYLGHV HTXDO RSSRUWXQLW\ LQ HPSOR\PHQW DQG SURJUDPV $X[LOLDU\ DLGV DQG VHUYLFHV DUH DYDLODEOH WR LQGLYLGXDOV ZLWK GLVDELOLWLHV XSRQ UHTXHVW )RU DVVLVWDQFH ZLWK WKLV IRUP FRQWDFW WKH $'$ &RRUGLQDWRU DW WKH 0DLQH :RUNHUV¶ &RPSHQVDWLRQ %RDUG 7HOHSKRQH RU 77< 0DLQH 5HOD\ :&% HII American LegalNet, Inc. www.FormsWorkFlow.com
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