SCHEDULE OF DEPENDENT(S) AND FILING STATUS STATEMENT STATE OF MAINE WORKERS' COMPENSATION BOARD STATION 27, AUGUSTA, MAINE 04333-0027 EMPLOYER/INSURER COMPLETES BOXES 1 TO 17 1. INSURER FILE NUMBER: 2. EMPLOYER NAME: 6. SOCIAL SECURITY NUMBER 8. EMPLOYEE LAST NAME: 7. WCB FILE NUMBER: 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: EMPLOYEE COMPLETES BOXES 18 TO 22 18. FEDERAL TAX FILING STATUS SINGLE SINGLE/HEAD OF HOUSEHOLD MARRIED/JOINT MARRIED/SEPARATE 19. DEPENDENT(S) DEPENDENT NAME(S) (IF NONE, SO STATE) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. (I.E., SPOUSE, DAUGHTER, SON) RELATIONSHIP DATE OF BIRTH SOCIAL SECURITY NUMBER (IF NONE, SO STATE) 20. PREPARER NAME AND TITLE (TYPE OR PRINT): 21. TELEPHONE NUMBER: 22. DATE MAILED: 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. WCB-2A (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com