Employers First Report Of Occupational Injury Or Disease {WCB-1}

EMPLOYER222S FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE : : REASON FOR REPORT (check all that apply) EMP LOYER (check one) INSURER THIRD PARTY ADMINISTRATOR (TPA) SELF-ADMINISTERED EMPLOYER EMPLOYEE CLAIM INFORMATION PREPARER INFORMATIO N THE STA TE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVIC ES, OR ACTIVITIES. THIS FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS222 COMPENSATION BOARD, ADA COORDINATOR, TELEPHONE: 1-888-801-9087 OR TTY Maine Relay 711. WCB - 1 (eff. 1/1/13 ) American LegalNet, Inc. www.FormsWorkFlow.com