NOTICE OF CONTROVERSY THIS IS A DENIAL OF YOUR BENEFITS 1. WCB FILE # (if known): EMPLOYEE 2. EMPLOYEE LAST NAME: 3. FIRST NAME: 4. MI: 5. EMPLOYEE ID : TYPE : #: 6. STREET/P.O. BOX MAILING ADDRES S: 7. CITY: 8. STATE: 9. ZIP: 10. HOME PHONE # : ( ) 11. DATE OF INJURY: // 12. SPECIFIC INJURY OR ILLNESS: 13. BODY PART(S) AFFECTED: EMPLOYER 14. INSURER /CLAIM ADMI N FILE # : 15. EMPLOYER NAME: 16. EMPLOYER MAILING ADDRESS AND PHONE # : 17. INSURER/ C LAIM A DMIN NAME AND ADDRESS: 18. INSURER/ C LAIM A DMIN FEIN : 19. NOTICE TO EMPLOYEE YOUR EMPLOYER/INSURER IS DENYING YOUR WORKERS222 COMPENSATION CLAIM OR PART OF IT. THE REASON FOR THE DENIAL IS CHECKED BELOW. IF YOU DISAGREE WITH THIS DENIAL, CONTACT A CLAIMS RESOLUTION SPECIALIST AT THE NEAREST REGIONAL OFFICE LISTED BELOW. 19a. FULL DENIAL REASON FULL DENIAL EFFECTIVE DATE // *NOTE: Reasons identified in boxes 19a or 19b will not preclude a party from raising additional issues at a later date. 19b. PARTIAL DENIAL REASON 20a. DATE OF INITIAL INCAPACITY // CURRENT DTE OF INCAPACITY // 20b. DATE EMPLOYER NOTIFIED // 2 1. COMMENTS: 22. If the employer fails to comply with the provi sions of Rule 1.1, the employee must be paid total benefits, with credit for earnings and other statutory offsets, from the date the claim is made in accordance with 39 -A M.R.S. 247 205(2) and in compliance with 39-A M.R.S. 247 204. The employer may discontinue benefits under this subsection when both of the following requirements are met: A. The employer files a Notice of Controversy; and B. The employer pays benefits from the date the claim is made. Payment under Rule 1.1 requires filing of a Memorandum of Payment. ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS222 COMPENSATION BOARD222S REGIONAL OFFICES AUGUSTA 442 CIVIC CTR DR, STE 225 156 STATE HOUSE STATION AUGUSTA, ME 04333-0156 (207) 287-2308 1 - 800 - 400 - 6854 BANGOR 106 HOGAN RD BANGOR, ME 04401-5638 (207) 941-4550 1 - 800 - 400 - 6856 CARIBOU ONE VAUGHN PL 43 HATCH DR, STE 110 CARIBOU, ME 04736 (207) 498-6428 1 - 800 - 400 - 6855 LEWISTON 36 MOLLISON WAY LEWISTON, ME 04240-7777 (207) 753-7700 1 - 800 - 400 - 6857 PORTLAND 1037 FOREST AVE, STE 11 PORTLAND, ME 04103 (207) 822-0840 1 - 800 - 400 - 6858 23. NAME (TYPE OR PRINT): E -MAIL ADDRESS: 24. TELEPHONE #: ( ) 25. DATE SENT TO WCB: // 26. DATE RCVD AT THE WCB (WCB use only) : // 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 Workers222 Compensation Board. Telephone: 1-888-801-9087 or TTY Maine Relay 711. WCB-9 (eff. 1/1/13, rev. 1/28/19) American LegalNet, Inc. www.FormsWorkFlow.com