Maine > Workers Compensation
Employers First Report Of Occupational Injury Or Disease WCB-1 - Maine
| Employers First Report Of Occupational Injury Or Disease Form. This is a Maine form and can be used in Workers Compensation . |
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1. WCB FILE NUMBER (if known): EMPLOYER'S FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE REASON FOR REPORT (check all that apply) 2a. LOST TIME - ONE OR MORE DAYS 3. 2b. WAS EMPLOYEE PAID FOR ½ DAY OR MORE ON DAY OF INJURY? 4. 6b. 7b. 1a. OSHA 300 CASE NUMBER (if applicable): LOST EARNINGS BUT NO LOST TIME MEDICAL/HEALTH CARE DATE OF LAST EXPOSURE: _____/_____/_____ MM DD YYYY DATE OF CORRECTION: _____/_____/_____ MM DD YYYY EMPLOYER 5. YES NO FATALITY DATE OF DEATH: _____/_____/_____ MM DD YYYY 6a. OCCUPATIONAL DISEASE 7a. CORRECT PRIOR REPORT 6c. DATE OF DIAGNOSIS AS OCCUPATIONALLY RELATED: ____/_____/_____ MM DD YYYY 7c. DATE CORRECTION SENT TO WCB: _____/_____/_____ MM DD YYYY 8. STATE EMPLOYER UNEMPLOYMENT INSURANCE ACCOUNT NUMBER (UIAN): 9. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): 10. EMPLOYER NAME: 11. STREET/P.O BOX MAILING ADDRESS: 12. CITY: 13. STATE: 14. ZIP: 15. TELEPHONE NUMBER: ( ) 16. PRIMARY BUSINESS PERFORMED BY EMPLOYER WHERE INJURY OCCURRED: 17. EMPLOYER LOCATION IF DIFFERENT FROM MAILING ADDRESS: 18. DID INJURY OR EXPOSURE OCCUR ON EMPLOYER'S PREMISES? YES NO IF NO, THEN GIVE NAME AND PHYSICAL ADDRESS OF THE EMPLOYER WHERE THE EMPLOYEE WAS INJURED OR EXPOSED: (check one) INSURER 20. POLICY NUMBER: THIRD PARTY ADMINISTRATOR (TPA) SELF-ADMINISTERED EMPLOYER 19. INSURANCE / TPA COMPANY NAME: 21. INSURER FILE NUMBER: 22. STREET/P.O. BOX MAILING ADDRESS: 23. CITY: 24. STATE: 25. ZIP: 26. TELEPHONE NUMBER: ( ) 32. GENDER: EMPLOYEE 27. LAST NAME: 28. FIRST NAME: 29. MI: 30. TELEPHONE NUMBER: ( ) 35. STATE: 36. ZIP: 31. SOCIAL SECURITY NUMBER: XXX-XX33. STREET/P.O. BOX MAILING ADDRESS: 34. CITY: 37. DATE OF BIRTH: MALE FEMALE 38. OCCUPATION/JOB TITLE: 39. DATE OF HIRE: _____/_____/_____ MM DD YYYY 40. WEEKLY WAGE AT TIME OF INJURY: $ CLAIM INFORMATION _____/_____/_____ MM DD YYYY 41. DOES EMPLOYEE WORK FOR ANOTHER EMPLOYER? YES NO IF YES, GIVE NAME AND ADDRESS: 42. DATE OF INJURY OR ILLNESS: _____/_____/_____ MM DD YYYY DATE EMPLOYER NOTIFIED: _____/_____/_____ MM DD YYYY 48. SPECIFIC INJURY OR ILLNESS (e.g. second degree burn or toxic hepatitis): 43. DATE OF INCAPACITY: _____/_____/_____ MM DD YYYY 44. TIME EMPLOYEE BEGAN WORK (e.g. 7:30 a.m.): 45. DATE EMPLOYER NOTIFIED INSURER/TPA: _____/_____/_____ MM DD YYYY 46. TIME OF INJURY (e.g. 1:10 p.m.): DATE EMPLOYER NOTIFIED: _____/_____/_____ MM DD YYYY 49. BODY PART(s) AFFECTED (e.g. lower right forearm): 47. HAS EMPLOYEE RETURNED TO WORK? YES NO IF YES, GIVE DATE: _____/_____/_____ MM DD YYYY 50. ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN THE EVENT OCCURRED (e.g. acetylene torch, metal plate): 51. SPECIFY ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE EVENT OCCURRED (e.g. cutting metal plate for flooring.): 52. HOW INJURY OR ILLNESS OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED OR MADE THE EMPLOYEE ILL. (e.g. worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against hot metal.): WAS ACTIVITY PART OF NORMAL JOB DUTIES? YES NO 53. HOSPITALIZED OVERNIGHT AS INPATIENT? YES NO 54. WAS THE EMPLOYEE TREATE 55. HEALTH CARE PROVICER NAME: IN AN EMERGENCY ROOM? 56. MAILING ADDRESS: YES NO: 57. TELEPHONE NUMBER: ( ) PREPARER INFORMATION 58. PREPARER NAME AND TITLE (TYPE OR PRINT): 59. TELEPHONE NUMBER: ( ) 60. DATE SENT TO WCB: _____/_____/_____ MM DD YYYY THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES, OR ACTIVITIES. THIS FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS' COMPENSATION BOARD, ADA COORDINATOR, TELEPHONE: 1-888-801-9087 OR TTY Maine Relay 711. WCB-1 (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com
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