Maine > Workers Compensation
Employment Status Report WCB-230 - Maine
| Employment Status Report Form. This is a Maine form and can be used in Workers Compensation . |
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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$0( EMPLOYMENT STATUS REPORT 62&,$/ 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 $1< (03/2<(5 5(48(67,1* $ 48$57(5/< 5(3257 0867 3529,'( 7+( (03/2<(( :,7+ 7+,6 )250 $7 /($67 '$<6 35,25 72 7+( '$7( 21 :+,&+ 7+( 5(3257 ,6 '8( 38568$17 72 $ 056$ NOTICE TO EMPLOYEE &203/(7( %2;(6 $1' $1' 5(7851 7+,6 5(3257 72 7+( (03/2<(5 /,67(' $%29( )$,/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 7+,6 5(3257 ,6 '8( BBBBBBBBBBBBBBBBBBBBBBBBBBB 7+,6 5(3257 &29(56 7+( 3(5,2' )520 BBBBBBBBBBBBBBBBBBBBBBBB72 BBBBBBBBBBBBBBBBBBBB PART II (COMPLETED BY THE EMPLOYEE) $ +$9( <28 %((1 (03/2<(' &+$1*(' (03/2<0(17 25 3(5)250(' $1< 6(59,&(6 )25 &203(16$7,21 '85,1* 7+( 3(5,2' 67$7(' ,1 7+( $%29( 6(&7,21" <(6 12 % ,) <(6 &203/(7( 7+( )2//2:,1* )25 ($&+ (03/2<(5 $1' $77$&+ 9(5,),&$7,21 2) ,1&20( (03/2<(5 1$0( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 7(/(3+21( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB $''5(66 BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB &,7< BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 67$7( BBBBBBBBBBBBB =,3 BBBBBBBBBBBBBBBBBBBBBBBBBBBBB 1$785( 2) 7+( (03/2<0(17 25 6(59,&(6 BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB (03/2<(' )520 BBBBBBBBBBBBBBBBBBBBBB 72 BBBBBBBBBBBBBBBBBBBBBB $5( <28 67,// (03/2<('" <(6 12 , +(5(%< &(57,)< 7+$7 7+( ,1)250$7,21 &217$,1(' ,1 7+,6 5(3257 ,6 7587+)8/ $1' $&&85$7( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB '$7( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB (03/2<(( 6,*1$785( 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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