Maine > Workers Compensation
Statement Of Compensation Paid WCB-11 - Maine
| Statement Of Compensation Paid 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 1. INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER (last 4 digits): 7. WCB FILE NUMBER: STATEMENT OF COMPENSATION PAID XXX-XX2. 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: 18. REASON FOR REPORT: INTERIM REPORT (ONGOING PAYMENTS OF ANY KIND) FINAL REPORT (NO FURTHER PAYMENTS ANTICIPATED) 19. LIST CUMULATIVE TOTALS (DO NOT INCLUDE ANY PENALTY AMOUNTS): MEDICAL TREATMENT $ DEATH BENEFIT/FUNERAL EXPENSE (NOT TO EXCEED $7,000.00) LEGAL EXPENSE (EMPLOYEE RELATED) LEGAL EXPENSE (EMPLOYER RELATED) INTEREST AND OTHER PAYMENTS $ PAYMENT SUMMARY WEEKLY COMPENSATION PERMANENT IMPAIRMENT (PRE 1993 ONLY) EMPLOYMENT REHABILITATION LUMP SUM SETTLEMENT $ $ $ $ $ $ $ TOTAL AMOUNT PAID (DO NOT REDUCE THESE TOTALS BY THE AMOUNT OF ANY RECOVERIES, INCLUDING DEDUCTIBLES) $ AUGUSTA 24 STONE ST, STE 102 AUGUSTA, ME 04330-5220 (207) 287-2308 1-800-400-6854 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 LEWISTON 36 MOLLISON WAY LEWISTON, ME 04240-7777 (207) 753-7700 1-800-400-6857 PORTLAND 62 ELM ST PORTLAND, ME 04101-3061 (207) 822-0840 1-800-400-6858 20. PREPARER NAME (TYPE OR PRINT): 21. TELEPHONE NUMBER: ( ) 22. DATE MAILED: 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-11 (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com
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