STATE OF MAINE WORKERS' COMPENSATION BOARD OFFICE OF MONITORING, AUDIT AND ENFORCEMENT 27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027 COMPLAINT FOR AUDIT PAUL R. LEPAGE GOVERNOR PAUL H. SIGHINOLFI, ESQ. EXECUTIVE DIRECTOR/CHAIR Insurer, Self-Administered Employer or Third-Party Adjusting Company (TPA) Name of Insurer, Self-Administered Employer or TPA: ___________________________________________________________ Claim Handler Name: _____________________________________________________________________________________ Street Address: __________________________________________________________________________________________ City/State/Zip Code: ______________________________________________________________________________________ Telephone: (_____)_______________________________________________________________________________________ Claim(s) Involved Workers’ Compensation Board File # (if available): _____________________________________________________________ Name of Employee: ______________________________________________________________________________________ Street Address: __________________________________________________________________________________________ City/State/Zip Code: ______________________________________________________________________________________ Telephone: (_____)_______________________________________________________________________________________ Social Security Number: ___________________________________________________________________________________ Date of Injury: ___________________________________________________________________________________________ Nature of Complaint (attach supporting documentation) _____________________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ The Complainant asks the Board to conduct an investigation to determine if the insurer, self-administered employer or third-party administrator has violated 39-A M.R.S.A. Section 359 by engaging in a pattern of questionable claims-handling techniques or repeated unreasonably contested claims and/or has violated Section 360(2) by committing a willful violation of the Act or committing fraud or intentional misrepresentation. The Complainant asks that the Board assess all applicable penalties. Party Filing Complaint Name: _________________________________________________________________________________________________ Street Address: ___________________________________________________________________________________________ City/State/Zip Code:_______________________________________________________________________________________ Telephone: (_____)________________________________________________________________________________________ ______________________________________ ____________________________________________ Signature of Complainant TEL: 207-287-7067 Rev. 12/11 Date of Complaint TTY: 877-832-5525 FAX: 207-287-7198 American LegalNet, Inc. www.FormsWorkFlow.com