WAGE STATEMENT 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): 8. EMPLOYEE LAST NAME: 7. WCB FILE NUMBER: 9. FIRST NAME: 10. M.I.: xxx -xx- 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. DOES EMPLOYEE WORK CONCURRENTLY FOR ANOTHER EMPLOYER? IF YES, GIVE NAME(S):____________________________ NOTE: THE EMPLOYER SHALL SUBMIT A WAGE STATEMENT FOR EACH ADDITIONAL EMPLOYER. WK 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 23. COMMENTS: WEEK ENDING GROSS EARNINGS WK 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 YES NO 19. DOES EMPLOYEE RECEIVE FRINGE BENEFITS THAT MAY STOP WHILE ON WORKERS' COMPENSATION? NOTE: THE EMPLOYER SHALL RECALCULATE THE AVERAGE WEEKLY WAGE IF/WHEN FRINGE BENEFITS CEASE (SEE RULE 1.5(2)) WEEK ENDING GROSS EARNINGS WK 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 WEEK ENDING YES NO GROSS EARNINGS 24. PREPARER NAME (TYPE OR PRINT): 25. TELEPHONE NUMBER: ( ) TOLL-FREE NUMBER: ( ) 26. 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: 1-888-801-9087 or TTY Maine Relay 711. WCB-2 (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com