Discontinuance Or Modification Of Compensation {WCB-4} | Pdf Fpdf Docx | Maine

 Maine /  Workers Compensation /
Discontinuance Or Modification Of Compensation {WCB-4} | Pdf Fpdf Docx | Maine

Discontinuance Or Modification Of Compensation {WCB-4}

This is a Maine form that can be used for Workers Compensation.

Alternate TextLast updated: 4/18/2019

Included Formats to Download
$ 13.99

Description

DISCONTINUANCE OR MODIFICATION OF COMPENSATION PURSUANT TO 39-A M.R.S.A. 247205(9)(A) 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): XXX-XX- 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: PLEASE COMPLETE EITHER THE SECTION FOR DISCONTINUANCE OR MODIFICATION, BUT NOT BOTH. DISCONTINUANCE 18 . REASON FOR DISCONTINUANCE: RETURNED TO WORK FOR SAME EMPLOYER RETURNED TO WORK FOR SAME EMPLOYER REGULAR/FULL DUTY MEDICAL RELEASE EARNING AT/ABOVE AVERAGE WEEKLY WAGE BOARD DECISION OTHER (EXPLAIN) 19. PERIOD OF INCAPACIT Y: FROM (DATE): TO: (RETURN DATE): 20. WEEKLY COMPENSATION RATE: 21. AMOUNT PAID: 22. DATE FINAL PAYMENT MAILED : 23. COMMENTS: MODIFICATION 2 4 . REASON FOR MODIFICATION: RETURNED TO WORK FOR SAME EMPLOYER COST OF LIVING ADJUSTMENT INCREASED/DECREASED EARNINGS WITH SAME EMPLOYER MODIFIED WORK/DUTY (PRE 1993 CLAIMS ONLY) BOARD DECISION MAX RATE INCREASE OTHER (EXPLAIN) 25 . OLD COMPENSATION RATE: 26 . NEW COMPENSATION RATE: 2 7 . EFFECTIVE DATE OF MODIFICATION: 2 8 . COMMENTS: ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS222 COMPENSATION BOARD222S REGIONAL OFFICES AUGUSTA 442 CIVIC CTR DR, STE 225 156 STATE HOUSE STATION AUGUSTA, ME 04333-0156 (207) 287-2308 1 - 800 - 400 - 6854 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 1037 FOREST AVE, STE 11 PORTLAND, ME 04103 (207) 822-0840 1 - 800 - 400 - 6858 29. PREPARER NAME (TY PE OR PRINT): E-MAIL ADDRESS: 30. TELEPHONE NUMBER: ( ) TOLL-FREE NUMBER: ( ) 31. DATE MAILED: // 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 Workers222 Compensation Board. Telephone: 1-888-801-9087 or TTY Maine Relay 711. WCB-4 (eff. 1/1/13, rev. 1/28/19) American LegalNet, Inc. www.FormsWorkFlow.com

Our Products