Maine > Workers Compensation
Notice Of Controversy WCB-9 - Maine
| Notice Of Controversy Form. This is a Maine form and can be used in Workers Compensation . |
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NOTICE OF CONTROVERSY THIS IS A DENIAL OF YOUR BENEFITS EMPLOYEE 3. FIRST NAME: 2. EMPLOYEE LAST NAME: 4. MI: 5. EMPLOYEE ID: TYPE: 9. ZIP: #: 1. WCB FILE # (if known): 6. STREET/P.O. BOX MAILING ADDRESS: 7. CITY: 8. STATE: 10. HOME PHONE #: ( ) 11. DATE OF INJURY: 12. SPECIFIC INJURY OR ILLNESS: 13. BODY PART(S) AFFECTED: _____/_____/_____ EMPLOYER 14. INSURER/CLAIM ADMIN FILE #: 15. EMPLOYER NAME: 16. EMPLOYER MAILING ADDRESS AND PHONE #: 17. INSURER/CLAIM ADMIN NAME AND ADDRESS: 18. INSURER/CLAIM ADMIN FEIN: 19. NOTICE TO EMPLOYEE YOUR EMPLOYER/INSURER IS DENYING YOUR WORKERS' COMPENSATION CLAIM OR PART OF IT. THE REASON FOR THE DENIAL IS CHECKED BELOW. IF YOU DISAGREE WITH THIS DENIAL, CONTACT A CLAIMS RESOLUTION SPECIALIST AT THE NEAREST REGIONAL OFFICE LISTED BELOW. 19b. 19a. FULL DENIAL REASON PARTIAL DENIAL REASON 20a. DATE OF INITIAL INCAPACITY ____/____/____ CURRENT DTE OF INCAPACITY ____/_____/_____ 20b. FULL DENIAL EFFECTIVE DATE _____/_____/_____ *NOTE: Reasons identified in boxes 19a or 19b will not preclude a party from raising additional issues at a later date. 21. COMMENTS: DATE EMPLOYER NOTIFIED _____/_____/_____ 22. If the employer fails to comply with the provisions of Rule 1.1, the employee must be paid total benefits, with credit for earnings and other statutory offsets, from the date the claim is made in accordance with 39-A M.R.S. § 205(2) and in compliance with 39-A M.R.S. § 204. The employer may discontinue benefits under this subsection when both of the following requirements are met: A. The employer files a Notice of Controversy; and B. The employer pays benefits from the date the claim is made. Payment under Rule 1.1 requires filing of a Memorandum of Payment. AUGUSTA 24 STONE ST, STE 102 AUGUSTA, ME 04330-5220 (207) 287-2308 1-800-400-6854 23. NAME (TYPE OR PRINT): ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS' COMPENSATION BOARD'S REGIONAL OFFICES BANGOR 106 HOGAN RD BANGOR, ME 04401-5638 (207) 941-4550 1-800-400-6856 CARIBOU ONE VAUGHN PL 43 HATCH DR, STE 110 CARIBOU, ME 04736 (207) 498-6428 1-800-400-6855 24. TELEPHONE #: LEWISTON PORTLAND 36 MOLLISON WAY 62 ELM ST LEWISTON, ME PORTLAND, ME 04240-7777 04101-3061 (207) 753-7700 (207) 822-0840 1-800-400-6857 1-800-400-6858 25. DATE SENT TO WCB: _____/_____/_____ ( E-MAIL ADDRESS: ) 26. DATE RCVD AT THE WCB (WCB use only): _____/_____/_____ 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-9 (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com
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