Fill and Sign the Notice of Controversy Mainegov Form

NOTICE OF CONTROVERSY THIS IS A DENIAL OF YOUR BENEFITS 1. W CB FILE # (if known): EMPLOYEE 2. EMPLOYEE LAST NAME: 3. FIRST NAME: 4. MI: 5. EMPLOYEE ID : TYPE : #: 6. STREET/P.O. BOX MAILING ADDRES S: 7. CITY: 8. STATE: 9. ZIP: 10. HOME PHONE #: ( ) 11. DATE OF INJURY: _____/_____/_____ 12. SPECIFIC INJURY OR ILLNESS: 13. BODY PART(S) AFFECTED: EMPLOYER 14. INSURER/CLAIM ADMIN FILE #: 15. EMPLOYER NAME: 16. EMPLOYER MAILING ADDRESS AND PHONE #: 17. INSURER/ CLAIM ADMIN NAME AND ADDRESS: 18. INSURER/CLAIM ADMIN FEIN : 19. NOTICE TO EMPLOYEE YOUR EMPLOYER/INSURER IS DENYING YOUR W ORKERS’ COMPENSATION CLAIM OR PART OF IT. THE RE ASON FOR THE DENIAL IS CHECKED BELOW . IF YOU DISAGREE W ITH THIS DENIAL, CONTACT A CLAIMS RESOLUTION SPECIALIST AT THE NEAREST R EGIONAL OFFICE LISTED BELOW . 19a. FULL DENIAL REASON FULL DENIAL EFFECTIVE DATE _____/_____/_____ *NOTE: Reasons identified in boxes 19a or 19b will not preclude a party from raising additional issues at a later date. 19b. P ARTI AL DE NI AL RE AS ON 20a. DATE OF INITIAL INCAPACITY ____/____/____ CURRENT DTE OF INCAPACITY ____/_____/_____ 20b. DATE EMPLOYER NOTIFIED _____/_____/_____ 21. COMMENTS: 22. If the employer fails to comply with the provisions of Rule 1.1, the employee must be paid total benefits , with credit for earnings and other statutory offsets, from the date the claim is made in accordance with 39 -A M.R.S. § 205(2) and in compliance with 39 -A M.R.S. § 204. The employer may discontinue benefits under this subsection when both of the following requirements are met: A. The employer files a Notice of Controversy; and B. The employer pays benefits from the date the claim is made. Payment under Rule 1.1 requires filing of a Memorandum of Payment. ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS’ COMPENSATION BOARD’S REGIONA L 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) 9 41-4550 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 04103 (207) 822 -0840 1-800 -400 -6858 23. NAME (TYPE OR PRINT): E-MAIL ADDRESS: 24. TELEPHONE #: ( ) 25. DATE SENT TO W CB: _____/_____/_____ 26. DATE RCVD AT THE W CB (W CB use only) : _____/_____/_____ 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’ Com pensation Board. Telephone: 1-88 8-801 -908 7 or TTY Maine Relay 711 . WCB -9 ( eff. 1/1/13 , rev. 1/28/19 )