Maine > Workers Compensation
Employers Supplemental Report WCB-12 - Maine
| Employers Supplemental Report Form. This is a Maine form and can be used in Workers Compensation . |
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EMPLOYERS SUPPLEMENTAL REPORT STATE OF MAINE WORKERS COMPENSATION BOARD STATION 27, AUGUSTA, MAINE 04333-0027 1. INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER 7. WCB FILE NUMBER: 2. 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: NOTICE TO EMPLOYER THIS REPORT IS USED ONLY WHEN THE EMPLOYEE LOSES A DAY OR MORE FROM WO RK THAT DOES NOT RESULT IN THE FILING OF A MEMORANDUM OF PAYMENT, A NOTICE OF CONT ROVERSY OR IF BOXES 39 AND 40 OF THE FIRST REPORT, WCB-1, ARE COMPLETED OR CORRECTED AS APPLICABLE. THE EMPLOYER SH ALL FILE THIS REPORT TO THE BOARD ADDRESS LISTED ABOVE WITHIN SEVEN DAYS OF THE EMPLOYEES RETURN TO WORK (SEE RULE 8.16) 18. ON WHAT DATE DID THIS EMPLOYEE BEGIN LOSING TIME FROM WORK? MONTH DAY YEAR HOUR AM / / : PM 19. ON WHAT DATE DID THE EMPLOYEE RETURN TO WORK? MONTH DAY YEAR HOUR AM / / : PM 20. IS THE INJURED EMPLOYEE EARNING THE SAME WEEKLY WAGES AS BEFORE THE INJURY? YES NO 21. DID THIS EMPLOYEE RETURN TO WORK WITH A DIFFERENT EM PLOYER? IF YES, GIVE NAME(S) YES NO 22. COMMENTS: ASSISTANCE IS AVALABLE AT THE BOARDS REGIONAL OFFICES: AUGUSTA BANGOR CARIBOU 24 STONE ST 106 HOGAN RD. ONE VAUGHN PLACE AUGUSTA, ME 04330-5220 BANGOR, ME 04401-5640 43 HATCH DR, STE 305 287-2168 941-4550 CARIBOU, ME 04736 1-800-400-6854 1-800-400-6856 498-6428 1-800-400-6855 LEWISTON PORTLAND 36 MOLLISON WAY 62 ELM ST LEWISTON, ME 04240-5811 PORTLAND, ME 04101-6858 753-7700 822-0840 1-800-400-6857 1-800-400-6858 21. PREPARER NAME AND TITLE (TYPE OR PRINT): 22. TELEPHONE 23. DATE: NUMBER: THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORM ATS SUCH AS BRAILLE, LARGE PRINT AND AUDIOTAPE. WCB 12 (8/94)
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