Fill and Sign the Certificate of Discontinuance or Mainegov Form

DISCONTINUANCE OR MODIFICATION OF COMPENSATION PURSUANT TO 39 -A M.R.S. A. §205(9)(A) 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): XX X-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: PLEASE COMPLETE EITHER THE SECTION FOR DISCONTINUANCE OR MODIFICATION, BUT NOT BOTH. DISCONTINUANCE 18. REASON FOR DISCONTINUAN CE: RETURNED TO W ORK FOR SAME EMPLOYER RETURNED TO W ORK FOR SAME EMPLOYER REGULAR/FULL DUTY MEDICAL RELEASE EARNING AT/ABOVE AVERAGE W EEKLY W AGE BOARD DECISION OTHER (EXPLAIN) ___________________________________________ 19. PERIOD OF INCAPACITY: FROM (DATE): TO: (RETURN DATE): 20. W EEKLY COMPENSATION RATE: 21. AMOUNT PAID: 22. DATE FINAL PAYMENT MAILED : 23. COMMENTS: MODIFICATION 24. REASON FOR MODIFICATION: RETURNED TO W ORK FOR SAME EMPLOYER COST OF LIVING ADJUSTMENT INCREASED/DECREASED EARNINGS W ITH SAME EMPLOYER MODIFIED W ORK/DUTY (PRE 1993 CLAIMS ONLY) BOARD DECISION MAX RATE INCREASE OTHER (EXPLAIN) __________________ ____________________ 25. OLD COMPENSATION RATE: 26. NEW COMPENSATION RATE: 27. EFFECTIVE DATE OF MODIFICATION: 28. COMMENTS: ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS’ COMPENSATION BOARD’S 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 W AY LEW ISTON, ME 04240 -7777 (207) 753 -7700 1-800 -400 -6857 PORTLAND 1037 FOREST AVE, STE 11 PORTLAND, ME 0410 3 (207) 822 -0840 1-800 -400 -6858 29. PREPARER NAME (TYPE OR PRINT): E-MAIL ADDRESS: 30. TELEPHONE NUMBER: ( ) TOLL-FREE NUMBER: ( ) 31. 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 W orkers’ Compensation Board. Telephone: 1 -888 -801 -9087 or TTY Maine Relay 711 . W CB -4 ( eff. 1/1/13 , rev. 1/28 /19)