Fill and Sign the Certificate Authorizing Release of Benefit Information Mainegov

1. INSURER FILE NUMBER: 2. EMPLOYER NAME: 10. M.I.: 3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: 4. INSURER NAME: 12. CITY:13. STATE:14. ZIP: 5. INSURER MAILING ADDRESS: 16. DATE OF INJURY: SO CIAL SECURITY ADMINISTRATION EM PLOYEE BENEFITS PLAN 1. EFFECTIVE DATE OF ELIGIBILITY: _____________________________________ 2. CURRENT GROSS MONTHLY AMOUNT: __________________________________ 3. PERCENTAGE OF EMPLOYEE BENEFIT PLAN PAID BY EMPLOYER (IF APPLICABLE): ________________________ 6. BENEFIT INFORMATION SENT TO THE EMPOYER/INSURER ON: ___________________________ SIGNATURE: _________________________________________________ DATE:_____________________ PREPARER NAME (TYPE OR PRINT):_______________________________ TELEPHONE NUMBER:__________________________ 8. EMPLOYEE LAST NAME: 6. SOCIAL SECURITY NUMBER (last 4 digits): THE EMPLOYEE AUTHORIZES THE RELEASE OF BENEFIT INFORMATION PURSUANT TO 39-A M.R.S.A. §221(5). PLEASE PROVIDE THE FOLLOWING INFORMATION TO THE EMPLOYER/INSUER: 4. IF BENEFITS FROM THIS EMPLOYEE BENEFIT PLAN ARE SUBJECT TO REDUCTION BASED ON RECEIPT OF WORKERS' COMPENSATION BENEFITS, PLEASE EXPLAIN: 5. C OMMENTS: CITY, STATE, ZIP I UNDERSTAND THAT THE EMPLOYER/INSURER IS ENTITLED TO RECEIVE THIS SOCIAL SECURITY OLD AGE INSURANCE OR EMPLOYEE BENEFIT PLAN INFORMATION PURSUANT TO 39-A M.R.S.A. §221(5) AND THAT MY FAILURE TO COMPLETE AND RETURN THIS REPORT MAY AFFECT MY WORKERS' COMPENSATION INDEMNITY BENEFITS. THIS CERTIFICATE OF RELEASE IS VALID FOR ONE YEAR FROM THE DATE OF MY SIGNATURE. SIGNATURE: _________________________________________________ DATE:_____________________ PART III (COMPLETED BY SOCIAL SECURITY ADMINISTRATION OR EMPLOYEE BENEFIT PLAN ADMINISTRATOR) 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-6 (eff. 1/1/13, revised 1/1/14) CERTIFICATE AUTHORIZING RELEASE OF BENEFIT INFORMATION STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 PART II (COMPLETED BY EMPLOYEE) I, _________________________________________________, DATE OF BIRTH ______________ AUTHORIZE THE EMPLOYER/INSURER TO OBTAIN WRITTEN INFORMATION INDICATING THE NATURE AND AMOUNT OF BENEFITS I RECEIVED OR AM RECEIVING FROM THE FOLLOWING: NAME OF EMPLOYEE BENEFIT PLAN ADDRESS- NUMBER AND STREET 9. FIRST NAME: 15. HOME PHONE: 7. WCB FILE NUMBER: 11. ADDRESS-NUMBER AND STREET: 17. DESCRIPTION OF INJURY: PART I (COMPLETED BY EMPLOYER/INSURER) 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 ): XXX- XX- 7. W CB FILE NUMBER: 2. 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 indiv iduals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers’ Com pensation Board. Telephone: 1- 888-801-9087 or TTY Maine Relay 711. WCB -7 ( eff. 01/ 1/13)