CERTIFICATE OF DISCONTINUANCE OR REDUCTION OF COMPENSATION PURSUANT TO 39-A M.R.S.A. 247205(9)(B)(1) STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 1. INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER (last 4 d igits): 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: NOTICE TO EMPLOYEE YOUR WEEKLY COMPENSATION BENEFITS WILL BE DISCONTINUED OR REDUCED 21 DAYS FROM THE DATE THIS CERTIFICATE WAS MAILED BASED ON THE ATTACHED INFORMATION. IF YOU DISAGREE WITH THIS ACTION, YOU MAY FILE A PETITION FOR REVIEW AND REQUEST REINSTATEMENT OF YOUR BENEFITS PENDING HEARING, UNDER 39-A M.R.S.A. 247205(9)(C). YOUR PETITION AND REQUEST (ON FORM WCB-121) MUST BE MAILED TO THE WORKERS' COMPENSATION BOARD ADDRESS ABOVE. 18 . REASON FOR DISCONTINUANCE OR REDUCTION ( MUST ATTACH SUPPORTING DOCUMENTATION) : DISCONTINUANCE 19. PERIOD OF INCAPACITY: FROM (DATE): TO (EFFECTIVE DATE OF DISCONTINUANCE): 20. WEEKLY COMPENSATION RATE: 21. COMPENSATION PA ID TO DATE OF CERTIFICATE: 22. COMPENSATION TO BE PAID FOR 21 DAY PERIOD: REDUCTION 23. OLD COMPENSATION RATE: 24. NEW COMPENSATION RATE: 25. EFFECTIVE DATE OF REDUCTIO N: 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 2 6 . PREPARER NAME (TYPE OR PRINT): E-MAIL ADDRESS: 27 . TELEPHONE NUMBER: ( ) TOLL-FREE NUMBER: ( ) 28 . DATE MAILED (MUST MATCH POSTMARK): // 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-8 (eff. 1/1/13, rev. 1/28/19) American LegalNet, Inc. www.FormsWorkFlow.com