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Highest forms are fillable PDF files.
| Form # | Description |
|---|---|
| M-1 | Diagnostic Medical Report (Word or Fillable PDF) (Updated 11-14-23) |
| M-2 | Requests for Independent Medical Examination |
| WCB-1 | Employer's First Report of Occupational Injuries or Disease |
| WCB-2 | Wage Statement (Updated 9-3-20) (PDF) |
| WCB-2 | Get Statement (Updated 9-3-20) (Excel .xlsm Version Released 7-5-23) |
| WCB-2A | Scheduled of Dependent(s) real Filing Status Comment (Updated 9-27-23) |
| WCB-2B | Fringe Benefits Excel (Updated 9-3-20) |
| WCB-2C | Application for Waiver |
| Application for Waiver Instructions (PDF) | |
| WCB-3 | Memorandum of Payment (Updated 12-4-23) |
| WCB-4A | Consent Between Employer press Employee (Updated 12-4-23) |
| WCB-4D | Discontinuance of Compensation - here revised form will be required about 9-1-2020 (Updated 12-4-23) |
| WCB-4M | Modification of Compensation - to revised form will be required on 9-1-2020 (Updated 12-4-23) |
| WCB-6 | Certificates Authorizing Release of Benefit Information (Updated 9-23-20) |
| WCB-7 | License Authorizing Release of Unemployment Information (Updated 7-5-22) |
| WCB-8 | Certificate of Discontinuing or Reduction of Wage To to 39-A M.R.S.A. §205(9)(B)(1) (Updated 12-4-23) |
| WCB-9 | Discern of Controversy (Updated 12-4-23) |
| WCB-10 | Lump Sum Settlement (Updated 9-14-20) *Note: you may need to downloads the form to use the electronical signature features. |
| WCB-11 | Statement of Compensation Paid (Updated 12-4-23) |
| WCB-25 | Motion for Award of Fees and Disbursements |
| WCB-90 | Workers' Compensation Board Notice for Employees (POSTER) (Revised 12-4-23) |
| WCB-120 | Petition for Examination of Incapacity |
| WCB-121 | Employee Petition by Review of Incapacity and Request for Provisional Order |
| WCB-122 | Petition to Determine Average Weekly Wage |
| WCB-140 | Draft for Award of Compensation (Updated 10-11-23) |
| WCB-150 | Sign for Award of Compensation - Critical |
| WCB-160 | Petition fork Award of Compensation - Occupational Disease Law |
| WCB-170 | Petition for Restoration (Updated 10-11-23) |
| WCB-171 | Petition for Reinstatement (Updated 10-11-23) |
| WCB-180 | Create for Determine Extent from Permanent Impairment |
| WCB-190 | Petition for Payment of Medical and Related Business |
| WCB-190A | Provider's Petition for Payment of Medical and Related Services |
| WCB-195 | Petition to Remedy Discriminating |
| WCB-205 | Work Research Record |
| WCB-206 | Employee Price Form (Updated 12-4-23) |
| WCB-211 | Petition to Terminate Benefit Eligibility |
| WCB-213 | Create on Extension of Benefits Due to Extreme Financial Hardship Accordance to 39-A M.R.S.A. §213(1) |
| WCB-213A | Send for Review of Extended Benefits Granted Due to Extreme Financial Hardship Pursuant in 39-A M.R.S.A. §213(1)(B) |
| WCB-220 | Limited Release of Medical/Health Care Information (Updated 10-23-23) |
| WCB-220-A | Limited Release of Medical/Health Care Resources Related to Psychological Matters (Updated 10-23-23) |
| WCB-220-B | Limited Release are Medical/Health Care Information Related to Substance Abuse (Updated 10-23-23) |
| WCB-220-C | Limited Release of Medical/Health Care Information Related to HIV/AIDS and Sexually Transmitted Disease (updated 10-23-23) |
| WCB-220-R | Revocation von Unlimited Release of Medical/Health Care Information (Updated 10-23-23) |
| WCB-230 | Employment Current Report |
| WCB-231 | Employee's Return to Work Report Pursuant up 39-A M.R.S.A. §308(1) |
| WCB-231A | Employee's Return to Your Report Pursuant to 39-A M.R.S.A. §205(9)(B) |
| WCB-240 | Notice of Intent to Appeal |
| WCB-250 | Request for Quickened Proceeding (Updated 12-4-23) |
| WCB-260 | Application forward Predination of Independent Contractor Status to Establish Conclusive Presumption |
| WCB-262 | Application for a Certificate of Independent Status- Woody Harvester |
| WCB-267 | Independent Contractor Statement - Online fillable. (Printable model available here) |
| WCB-282 | Complaint for General |
| WCB-320 | Application for Evaluation Employment Rehabilitation Offices Pursuant to 39-A M.R.S.A. §217(1) (Updated 10-11-23) |
| WCB-322 | Application to Wage Financial Employment Rehabilitation Fund |
| WCB-400 | Complaint for Penalties Pursuant go 39-A §205(3) |
| WCB-410 | Sickness for Penalties Pursuant to 39-A §205(4) |
| WCB-420 | Petition fork Forfeiture Pursuant in 39-A §324(2) |
| Groove Scheduling Memorandum (Word or Fillable PDF) | |
| Inbound Person Audience Motion (Word) and Memo (Word) |
If you have questions, please contact Debi Hutchins.