EMPLOYEE'S RETURN TO WORK REPORT STATE OF MAINE WORKERS' COMPENSATION BOARD STATION 27, AUGUSTA, MAINE 04333-0027 PART 1 (COMPLETED BY EMPLOYER/INSURER) 1. INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER 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: 18. NOTICE TO EMPLOYER/INSURER THIS REPORT IS SENT TO THE EMPLOYEE WITH THE 21-DAY CERTIFICATE OF DISCONTINUANCE OR REDUCTION OF COMPENSATION OR THE PETITION FOR REVIEW PURSUANT TO RULE 8.15. 19. NOTICE TO EMPLOYEE YOUR WEEKLY BENEFITS WILL BE REDUCED OR DISCONTINUED EACH WEEK TO THE AMOUNT SHOWN ON THE CERTIFICATE OF DISCONTINUANCE OR REDUCTION OF COMPENSATION OR PETITION FOR REVIEW. YOU ARE REQUIRED TO PROVIDE DOCUMENTATION TO THE INSURER OF YOUR WEEKLY EARNINGS FOR THE 21-DAY PERIOD OR WHILE THE PETITION FOR REVIEW IS PENDING BEFORE THE WORKERS' COMPENSATION BOARD BY COMPLETING THE INFORMATION IN BOX 20 BELOW. IF YOU FAIL TO PROVIDE DOCUMENTATION, THE REDUCTION SHOWN ON THE CERTIFICATE OF DISCONTINANCE OR REDUCTION OR PETITION FOR REVIEW SHALL REMAIN IN EFFECT AND YOUR BENEFITS WILL NOT BE ADJUSTED. PART 2 (COMPLETED BY THE EMPLOYEE) 20. COMPLETE THE FOLLOWING INFORMATION. A. INCOME FROM NEW EMPLOYMENT (attach verification): PAY PERIOD ENDING DATE ______________________ PAY PERIOD ENDING DATE ______________________ PAY PERIOD ENDING DATE ______________________ PAY PERIOD ENDING DATE ______________________ B. COMMENTS: AMOUNT _________________________ AMOUNT _________________________ AMOUNT _________________________ AMOUNT _________________________ 21. I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS REPORT IS TRUTHFUL AND ACCURATE. _________________________________________________________ EMPLOYEE SIGNATURE ______________________________________ DATE THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES, OR ACTIVITIES. THIS FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS' COMPENSATION BOARD, ADA COORDINATOR, TELEPHONE: 1-888-801-9087 OR TTY Maine Relay 711. American LegalNet, Inc. WCB-231A (eff. 1/1/13) www.FormsWorkFlow.com