FRINGE BENEFITS WORKSHEET STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 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. EMPLOYEE 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: PROVIDE THE COST OF THE FRINGE BENEFIT PAID BY THE EMPLOYER AS OF THE EMPLOYEE'S DATE OF INJURY IF THE EMPLOYEE WAS RECEIVING THE BENEFIT ON HIS/HER DATE OF INJURY (SEE RULE CHAPTER 1(5)(1)). NOTE: THE AMOUNTS REPORTED ARE SUBJECT TO VERIFICATION BY THE EMPLOYEE AND HIS/HER REPRESENTATIVE AND DOCUMENTATION MUST BE PROVIDED UPON REQUEST. 18. Fringe Benefit Health Benefits (inc. insurance) Dental Insurance Disability Insurance (inc. short and long term) 401K Life Insurance Education/Training Pension Other (please list): Other (please list): Yes Yes Provided No No Continues while Employee is out of work Yes Yes No No Date Benefits End $ $ $ $ $ $ $ $ $ 20. TELEPHONE NUMBER: ( ) TOLL-FREE NUMBER: ( ) Weekly Cost of Benefits to Employer Yes Yes Yes Yes Yes Yes Yes No No No No No No No Yes Yes Yes Yes Yes Yes Yes No No No No No No No 19. PREPARER NAME (TYPE OR PRINT): 21. DATE MAILED: _____/_____/_____ MM DD YYYY E-MAIL ADDRESS: 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: (888) 801-9087 or TTY Maine Relay 711. WCB-2B (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com