STATEMENT OF COMPENSATION PAID STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 1. INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER (last 4 digits): XXX-XX- 7. WCB FILE NUMBER: 2. EMPLOYER NAME: 8. EM PLOYEE 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: 18. REASON FOR REPORT: INTERIM REPORT (ONGOING PAYMENTS OF ANY KIND) FINAL REPORT (NO FURTHER PAYMENTS ANTICIPATED) PAYMENT SUMMARY 19 . LIS T CUMULATIVE TOTAL S (DO NOT INCLUDE ANY PENALTY AMOUNTS) : MEDICAL TREATMENT $ DEATH BENEFIT/FUNERAL EXPENSE (NOT TO EXCEED $7,000.00) $ WEEKLY COMPENSATION $ LEGAL EXPENSE (EMPLOYEE RELATED) $ PERMANENT IMPAIRMENT (PRE 1993 ONLY) $ LEGAL EXPENSE (EMPLOYER RELATED) $ EMPLOYMENT R EHAB ILITATION $ INTEREST AND OTHER PAYMENTS $ LUMP SUM SETTLEMENT $ TOTAL AMOUNT PAID (DO NOT REDUCE THESE TOTALS BY THE AMOUNT OF ANY RECOVERIES, INCLUDING DEDUCTIBLES) $ 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 20 . PREPARER NAME (TYPE OR PRINT): E-MAIL ADDRESS: 21 . TELEPHONE NUMBER: ( ) TOLL-FREE NUMBER: ( ) 22 . DATE MAILED : // MM DD YYYY 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-11 (eff. 1/1/13, rev. 1/28/19) American LegalNet, Inc. www.FormsWorkFlow.com