CERTIFICATE AUTHORIZING RELEASE OF UNEMPLOYMENT INFORMATION STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 PART I (COMPLETED BY REQUESTOR) 1. INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER (last 4 digits): 7. WCB FILE NUMBER: XXX-XX2. 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: PART II (COMPLETED BY EMPLOYEE) I, ____________________________________, understand that the information in my unemployment compensation file(s) is confidential under 26 M.R.S.A. §1082(7), of the Maine Revised Statutes. However, I waive my right to confidentiality and authorize the Workers' Compensation Board to obtain and release that information, pertaining to the benefit year ending ____/____/____, or calendar period from ________________ through __________________ to the following: Name: Title: Address: ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ I understand that I may also request a copy of this information be sent to me. A copy of this waiver/consent is acceptable. Signature:_________________________ Date:_____________________ PART III (COMPLETED BY THE WORKERS' COMPENSATION BOARD) Unemployment information sent to the requestor on __________________________________. Signature:_________________________ Date:_____________________ 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-7 (eff. 01/1/13) American LegalNet, Inc. www.FormsWorkFlow.com