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Wage Statement: XXX - XX

The document is a wage statement form from the Maine Workers' Compensation Board. It requests information about an employee's employer, insurers, injury details, earnings history, and average weekly wage to determine compensation.

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abdalazeez20122013
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102 views

Wage Statement: XXX - XX

The document is a wage statement form from the Maine Workers' Compensation Board. It requests information about an employee's employer, insurers, injury details, earnings history, and average weekly wage to determine compensation.

Uploaded by

abdalazeez20122013
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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WAGE STATEMENT

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:

xxx -xx-
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:

18. DOES EMPLOYEE WORK CONCURRENTLY 19. DOES EMPLOYEE RECEIVE FRINGE BENEFITS THAT MAY STOP
FOR ANOTHER EMPLOYER? YES WHILE ON WORKERS’ COMPENSATION? YES
IF YES, GIVE NAME(S):____________________________ NO NOTE: THE EMPLOYER SHALL RECALCULATE THE AVERAGE NO
NOTE: THE EMPLOYER SHALL SUBMIT A WAGE WEEKLY WAGE IF/WHEN FRINGE BENEFITS CEASE (SEE RULE
STATEMENT FOR EACH ADDITIONAL EMPLOYER. 1.5(2))
/,67*5266($51,1*6)25($&+:((.
WK WEEK ENDING GROSS EARNINGS WK WEEK ENDING GROSS EARNINGS WK WEEK ENDING GROSS EARNINGS
1 19 37

2 20 38

3 21 39

4 22 40

5 23 41

6 24 42

7 25 43

8 26 44

9 27 45

10 28 46

11 29 47

12 30 48

13 31 49

14 32 50

15 33 51

16 34 :.2)
,1-85<
17 35 727$/
($51,1*6
18 36 *5266$9(5$*(
:((./<:$*(
23. COMMENTS:

24. PREPARER NAME (TYPE OR PRINT): 25. TELEPHONE NUMBER: 26. DATE MAILED:
( )

TOLL-FREE NUMBER: _____/_____/_____


E-MAIL ADDRESS: ( ) 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-2 (eff. 1/1/13)

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