Maine > Workers Compensation
Memorandum Of Payment WCB-3 - Maine
| Memorandum Of Payment Form. This is a Maine form and can be used in Workers Compensation . |
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1. REVISION DATE: _____/_____/_____ MM DD YYYY 3. EMPLOYEE LAST NAME: MEMORANDUM OF PAYMENT EMPLOYEE 4. FIRST NAME: 5. MI.: 2. WCB FILE NUMBER (if known): 6. SOCIAL SECURITY NUMBER (last 4 digits): XXX-XX7. STREET/P.O. BOX MAILING ADDRESS: 8. CITY: 9. STATE: 10. ZIP: 11. HOME PHONE NUMBER: ( 12. DATE OF INJURY: _____/_____/_____ MM DD YYYY 13. SPECIFIC INJURY OR ILLNESS: 14. BODY PARTS (S) AFFECTED: ) EMPLOYER 15. INSURER FILE NUMBER: 16. EMPLOYER NAME: 17. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: 18. INSURER NAME: 19.INSURER MAILING ADDRESS AND PHONE NUMBER: NOTICE TO EMPLOYEE 20. YOUR EMPLOYER/INSURER IS REQUIRED TO FILE THIS WORKERS' COMPENSATION FORM UPON PAYMENT OF A LOST TIME WORK-RELATED INJURY. PAYMENT IS MADE FOR THE FOLLOWING REASON: A. B. C. YOUR CLAIM IS ACCEPTED. THIS IS A VOLUNTARY PAYMENT PENDING INVESTIGATION. THIS IS A MANDATORY PAYMENT PURSUANT TO RULE 1.1. AMOUNT PAID $ ________________. PERIOD COVERED BY MANDATORY PAYMENT: FROM (DATE CLAIM MADE) _____/_____/_____ THROUGH (DATE NOTICE OF CONTROVERSY FILED AND BENEFITS PAID) MM DD YYYY ______/_____/_____ MM DD YYYY 21. TYPE OF PAYMENT: A. B. C. 22. FIRST DAY OF COMPENSABILITY AFTER WAITING PERIOD WAS MET: WEEKLY COMPENSATION SPECIFIC LOSS: _________ WEEKS OTHER (EXPLAIN): ___________________________________________________________________________ _____/_____/_____ MM DD YYYY 23. DATE OF INCAPACITY: _____/_____/_____ MM DD YYYY 24. DATE CHECK MAILED: 25. AVERAGE WEEKLY WAGE: 26. CURRENT WEEKLY COMPENSATION RATE: TOTAL PARTIAL DATE EMPLOYER NOTIFIED OF INCAPACITY: _____/_____/_____ MM DD YYYY 27. IS THIS AN APPORTIONMENT CLAIM? YES _____/_____/_____ MM DD YYYY $ $ (IF VARYING RATES ARE BEING PAID, ENTER THE WORD "VARYING") NO IF YES, ANSWER THE FOLLOWING: OTHER DATE(S) OF INJURY INVOLVED: ______________________________________________________________________________________________________ OTHER INSURER(S) INVOLVED: ____________________________________________________________________________________________________________ EXPLAIN THE TERMS OF THE APPORTIONMENT: _____________________________________________________________________________________________ ____________________________________________________________ 28. COMMENTS: AUGUSTA 24 STONE ST, STE 102 AUGUSTA, ME 04330-5220 (207) 287-2308 1-800-400-6854 29. PREPARER NAME (TYPE OR PRINT): ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS' COMPENSATION BOARD'S REGIONAL OFFICES BANGOR CARIBOU 106 HOGAN RD ONE VAUGHN PL BANGOR, ME 43 HATCH DR, STE 110 04401-5638 CARIBOU, ME 04736 (207) 941-4550 (207) 498-6428 1-800-400-6856 1-800-400-6855 30. TELEPHONE NUMBER: ( ) LEWISTON 36 MOLLISON WAY LEWISTON, ME 04240-7777 (207) 753-7700 1-800-400-6857 31. DATE MAILED: PORTLAND 62 ELM ST PORTLAND, ME 04101-3061 (207) 822-0840 1-800-400-6858 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-3 (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com
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