Fill and Sign the Employees Return to Work Report Form

EMPLOYEE'S RETURN TO WORK REPORT STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION , AUGUSTA, MAINE 04333 -0027 PART I (COMPLETED BY EMPLOYER/INSURER ) 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: 18. NOTICE TO EMPLOYER/INSURER THE EMPLOYER/INSURER SHALL SEND THE EMPLOYEE'S RETURN TO WORK REPORT TO THE EMPLOYEE WHEN FILING THE MEMORAND UM OF PAYMENT PURSUANT TO 90 MAR 351 CH. 8. §17. 19. NOTICE TO EMPLOYEE IF YOU RETURN TO WORK WITH A NEW EMPLOYER, COMPLETE BOX ES 20 AND 21 AND FILE COPIES OF THIS REPORT WITH THE BOARD AND YOUR PREVIOUS EMPLOYER AT THE ADDRESSES LISTED ABOVE WIITHIN 7 DAYS PURSUANT TO 39 -A M.R.S.A. §308(1). FAILURE TO COMPLETE AND RETURN THIS REPORT MAY AFFECT YOUR WORKERS' COMPENSATION INDEMNITY BENEFITS. PART II (COMPLETED BY THE EMPLOYEE) 20. COMPLETE THE FOLLOWING INFORMATION (USE REVERSE SIDE IF NECESSARY). A. N EW EMPLOYER NAME: _______________________________ TELEPHONE: ________________________________ ADDRESS: _______________________________________________________________________________________ CITY: ____________________________________ STATE: _____________ ZIP: _____________________________ B. DATE OF HIRE: ___________________________________________ C. ATTACH VERIFICATION OF INCOME OR LIST ANTICIPATED INCOME: ______________________________________ __________________________________________________________________________________________________ D. COMMENTS: 21. I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS REPORT IS TRUTHFUL AND ACCURATE. _________________________________________________________ __________________________________ EMPLOYEE SIGNATURE DATE 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 -231 (eff. 1/1/13) EMPLOYEE'\b RETURN TO WORK REPORT \bTATE OF MAINE  WORKE R\b' COMPEN\bATION BOARD  \bTATION 27, AUGU\bTA, MAINE 04333-0027     PART 1 (\bOMPLETED BY EMPLOYER/INSURER)   1. INSU\bE\b FILE NUMBE\b:    6. SOCIAL SECU\bITY NUMBE\b  7. W CB FILE NUMBE\b: ;;;;;   2. EMPLOYE\b NAME:    8. EMPLOYEE LAST NAME:   9. FI\bST NAME:  10. M.I.:   3. EMPLOYE\b MAILING ADD\bESS AND PHONE NUMBE\b:                                                         11. ADD\bESS-NUMBE\b AND ST\bEET:   4. INSU\bE\b NAME:   12. CITY:  13. STATE:   14. ZIP:   15. HOME PHONE:   5. INSU\bE\b MAILING ADD\bESS:  16. DATE OF INJU\bY:  17. DESC\bIPTION OF INJU\bY:     18.  NOTI\bE TO EMPLOYER/INSURER    THIS  \bEPO\bT IS SENT TO THE EMPLOYEE WITH THE 21-DAY CE\bTIFICATE OF DISCONTINUANCE O\b \bEDUCTION OF  COMPENSATION O\b THE PETITION FO\b \bEVIEW PU\bSUANT TO \bULE 8.15.  19.  NOTI\bE TO EMPLOYEE   YOU\b W EEKLY BENEFITS WILL BE \bEDUCED O\b DISCONTINUED EACH WEEK TO THE AMOUNT SHOWN ON THE  CE\bTIFICATE OF DISCONTINUANCE O\b \bEDUCTION OF COMPENSATION O\b PETITION FO\b \bEVIEW.  YOU A\bE \bEQUI\bED  TO P\bOVIDE DOCUMENTATION TO THE INSU\bE\b OF YOU\b WEEKLY EA\bNINGS FO\b THE 21-DAY PE\bIOD O\b WHILE THE  PETITION FO\b \bEVIEW IS PENDING BEFO\bE THE WO\bKE\bS’ COMPENSATION BOA\bD BY COMPLETING THE INFO\bMATION IN  BOX 20 BELOW.  IF YOU FAIL TO P\bOVIDE DOCUMENTATION, THE \bEDUCTION SHOWN ON THE CE\bTIFICATE OF  DISCONTINANCE O\b \bEDUCTION O\b PETITION FO\b \bEVIEW SHALL \bEMAIN IN EFFECT AND YOU\b BENEFITS WILL NOT BE  ADJUSTED.      PART 2 (\bOMPLETED BY THE EMPLOYEE)   20. \bOMPLETE THE FOLLOWING INFORMATION.    A.  INCOME F\bOM NEW  EMPLOYMENT (attach verification):    PAY P E \bIOD ENDING DATE ______________________     AMOUNT _________________________      PAY PE\bIOD ENDING DATE ______________________     AMOUNT _________________________      PAY PE\bIOD ENDING DATE ______________________     AMOUNT _________________________      PAY PE\bIOD ENDING DATE ______________________     AMOUNT _________________________       B.  COMMENTS:               21. I HE\bEBY CE\bTIFY THAT THE INFO\bMATION CONTAINED IN THIS \bEPO\bT IS T\bUTHFUL AND ACCU\bATE.      _________________________________________________________      ______________________________________                                         EMPLOYEE SIGNATU\bE                                                                                            DATE     THE STATE OF MAINE DOES NOT DISC\bIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, O\b OPE\bATION OF ITS P\bOG\bAMS, SE\bVICES, O\b ACTIVITIES.   THIS FO\bM IS AVAILABLE IN ALTE\bNATIVE FO\bMAT. FO\b FU\bTHE\b ASSISTANCE, CONTACT THE MAINE W O\bKE\bS’ COMPENSATION BOA\bD, ADA COO\bDINATO\b, TELEPHONE:   1-888-801-9087 O\b TTY Maine Relay 711. W CB- 231A (eff. 1/1/13 )