STATE OF MAINE WORKERS' COMPENSATION BOARD OFFICE OF MONITORING, AUDIT AND ENFORCEMENT 27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027 JANET T. MILLS COMPLAINT FOR AUDIT JOHN C. ROHDE GOVERNOR E TEL: 207 �-- 287 �-- 3751 TTY: Maine Relay 711 FAX: 207 �-- 287 �-- 7198 WCB �-- 282 (eff. 1/1/13, rev. 2/25/19) Name of Insurer, Self �-- Administered Employer or TPA: Claim Handler Name: Street Address: City/State/Zip Code: 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 Party Filing Complaint Name: Street Address: City/State/Zip Code: Telephone: ()American LegalNet, Inc. www.FormsWorkFlow.com