EMPLOYMENT STATUS REPORT STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 PART I (COMPLETED BY EMPLOYER/INSURER) 1. INSURER FILE NUMBER: 2. EMPLOYER NAME: 6. SOCIAL SECURITY NUMBER (last 4 digits): 7. WCB FILE NUMBER: 9. FIRST NAME: 10. M.I.: XXX-XX8. EMPLOYEE LAST NAME: 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 ANY EMPLOYER REQUESTING A QUARTERLY REPORT MUST PROVIDE THE EMPLOYEE WITH THIS FORM AT LEAST 15 DAYS PRIOR TO THE DATE ON WHICH THE REPORT IS DUE , PURSUANT TO 39-A M.R.S.A. §308(2). 19. NOTICE TO EMPLOYEE COMPLETE BOXES 20 AND 21AND RETURN THIS REPORT TO THE EMPLOYER LISTED ABOVE. FAILURE TO COMPLETE AND RETURN THIS REPORT MAY AFFECT YOUR WORKERS' COMPENSATION INDEMNITY BENEFITS. THIS REPORT IS DUE: ___________________________ THIS REPORT COVERS THE PERIOD FROM ________________________TO ____________________ PART II (COMPLETED BY THE EMPLOYEE) 20. A. HAVE YOU BEEN EMPLOYED, CHANGED EMPLOYMENT OR PERFORMED ANY SERVICES FOR COMPENSATION DURING THE PERIOD STATED IN THE ABOVE SECTION? YES NO B. IF YES, COMPLETE THE FOLLOWING FOR EACH EMPLOYER AND ATTACH VERIFICATION OF INCOME: EMPLOYER NAME: ___________________________________ TELEPHONE: ________________________________ ADDRESS: _______________________________________________________________________________________ CITY: ____________________________________ STATE: _____________ ZIP: _____________________________ NATURE OF THE EMPLOYMENT OR SERVICES __________________________________________________________ EMPLOYED FROM: ______________________ TO ______________________ ARE YOU STILL EMPLOYED? YES NO 21. I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS REPORT IS TRUTHFUL AND ACCURATE. ______________________________________ DATE _________________________________________________________ EMPLOYEE SIGNATURE 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 Workers' Compensation Board. Telephone: 1-888-801-9087 or TTY Maine Relay 711. WCB-230 (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com