The Maine Workers’ Compensation Board has revised several forms, which are now available here.

The WCB-4 (Discontinuance/Modification) has been divided into two new forms, WCB-4D (Discontinuance) and WCB-4M (Modification). The Discontinuance, Modification, and Memorandum of Payment forms have been modified with substantive changes. Several others have been adjusted to have consistent headers (see boxes 1-18). Revisions for the Notice of Controversy are only for the paper version of that form.

While the effective date of these forms is September 1, 2020, the Board understands that target date may not be feasible due to this late notice. The Board asks that the new forms be used as soon as possible, but no later than January 1, 2021.

The following forms have been changed/updated:

WCB-2: Wage Statement

WCB-2A: Schedule of Dependent(s) and Filing Status Statement

WCB-2B: Fringe Benefits Worksheet

WCB-3: Memorandum of Payment

WCB-4A: Consent Between Employer and Employee

WCB-4D: Discontinuance of Compensation

WCB-4M: Modification of Compensation

WCB-6: Certificate Authorizing Release of Benefit Information

WCB-7: Certificate Authorizing Release of Unemployment Information

WCB-8: Certificate of Discontinuance or Reduction of Compensation

WCB-9: Notice of Controversy

WCB-10: Lump Sum Settlement

WCB-11: Statement of Compensation Paid