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Fill and Sign the Statement of Compensation Paid Form

Fill and Sign the Statement of Compensation Paid Form

How it works

Open the document and fill out all its fields.
Apply your legally-binding eSignature.
Save and invite other recipients to sign it.

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STATEMENT OF COMPENSATION PAID 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): XXX-XX- 7. W CB FILE NUMBER: 2. EMPLOYER NAME: 8. EM PLOYEE 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. REASON FOR REPORT: INTERIM REPORT (ONGOING PAYMENTS OF ANY KIND) FINAL REPORT (NO FURTHER PAYMENTS ANTICIPATED) PAYMENT SUMMARY 19 . LIS T CUMULATIVE TOTAL S (DO NOT INCLUDE ANY PENALTY AMOUNTS) : MEDICAL TREATMENT \ $ DEATH BENEFIT/FUNERAL EXPENSE (NOT TO EXCEED $7,000.00) $ W EEKLY COMPENSATION $ LEGAL EXPENSE (EMPLOYEE RELATED) $ PERMANENT IMPAIRMENT (PRE 1993 ONLY) $ LEGAL EXPENSE (EMPLOYER RELATED) $ EMPLOYMENT REHAB ILITATION $ INTEREST AND OTHER PAYMENTS $ LUMP SUM SETTLEMENT $ TOTAL AMOUNT PAID (DO NOT REDUCE THESE TOTALS BY THE AMOUNT OF ANY RECOVERIES, INCLUDING DEDUCTIBLES) $ ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS’ COMPENSATION BOARD’S REGIONAL OFFICES AUGUSTA 442 CIVIC CTR DR, STE 225 156 STATE HOUSE STATION AUG USTA, 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 04103 (207) 822- 0840 1-800 -400 -6858 20. PREPARER NAME (TYPE OR PRINT): E-MAIL ADDRESS: 21. TELEPHONE NUMBER: ( ) TOLL- FREE NUMBER: ( ) 22. DATE MAILED : _____/_____/_____ MM DD YYYY 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’ Compensation Board. Telephone: 1 -888 -801- 9087 or TTY Maine Relay 711. WCB -11 ( eff. 1/1/13 , rev. 1/28/19)

Useful suggestions for finishing your ‘Statement Of Compensation Paid’ online

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Follow this detailed guide:

  1. Log into your account or register for a complimentary trial with our service.
  2. Click +Create to upload a document from your device, cloud, or our template collection.
  3. Open your ‘Statement Of Compensation Paid’ in the editor.
  4. Click Me (Fill Out Now) to set up the document on your end.
  5. Insert and allocate fillable fields for other participants (if required).
  6. Continue with the Send Invite settings to solicit eSignatures from others.
  7. Download, print your version, or convert it into a reusable template.

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Here is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.

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The best way to complete and sign your statement of compensation paid form

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How to Sign a PDF Online How to Sign a PDF Online

How to fill out and sign paperwork online

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  • 2.Click Upload or Create and add a file for eSigning from your device, the cloud, or our form collection.
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  • 4.Place the My Signature field where you need to approve your form. Provide your name, draw, or upload a photo of your regular signature.
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How to fill out and sign paperwork in Google Chrome

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Follow the step-by-step guide to eSign your statement of compensation paid form template in Google Chrome:

  • 1.Go to the Chrome Web Store, search for the airSlate SignNow extension for Chrome, and add it to your browser.
  • 2.Right-click on the link to a document you need to sign and choose Open in airSlate SignNow.
  • 3.Log in to your account using your credentials or Google/Facebook sign-in option. If you don’t have one, you can start a free trial.
  • 4.Utilize the Edit & Sign toolbar on the left to fill out your template, then drag and drop the My Signature field.
  • 5.Add a photo of your handwritten signature, draw it, or simply enter your full name to eSign.
  • 6.Verify all data is correct and click Save and Close to finish modifying your form.

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How to fill out and sign paperwork in Gmail

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Follow the step-by-step guidelines to eSign your statement of compensation paid form in Gmail:

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  • 2.Install the tool with a related button and grant the tool access to your Google account.
  • 3.Open an email containing an attachment that needs signing and utilize the S symbol on the right panel to launch the add-on.
  • 4.Log in to your airSlate SignNow account. Select Send to Sign to forward the file to other people for approval or click Upload to open it in the editor.
  • 5.Put the My Signature option where you need to eSign: type, draw, or import your signature.

This eSigning process saves time and only requires a few clicks. Utilize the airSlate SignNow add-on for Gmail to adjust your statement of compensation paid form with fillable fields, sign paperwork legally, and invite other parties to eSign them al without leaving your mailbox. Improve your signature workflows now!

How to Sign a PDF on a Mobile Device How to Sign a PDF on a Mobile Device How to Sign a PDF on a Mobile Device

How to complete and sign forms in a mobile browser

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Follow the step-by-step guide to eSign your statement of compensation paid form in a browser:

  • 1.Open any browser on your device and follow the link www.signnow.com
  • 2.Register for an account with a free trial or log in with your password credentials or SSO authentication.
  • 3.Click Upload or Create and add a file that needs to be completed from a cloud, your device, or our form library with ready-to go templates.
  • 4.Open the form and fill out the empty fields with tools from Edit & Sign menu on the left.
  • 5.Place the My Signature area to the form, then enter your name, draw, or add your signature.

In a few simple clicks, your statement of compensation paid form is completed from wherever you are. As soon as you're done with editing, you can save the document on your device, build a reusable template for it, email it to other individuals, or ask them to eSign it. Make your documents on the go prompt and effective with airSlate SignNow!

How to Sign a PDF on iPhone How to Sign a PDF on iPhone

How to complete and sign forms on iOS

In today’s business community, tasks must be completed quickly even when you’re away from your computer. Using the airSlate SignNow application, you can organize your paperwork and approve your statement of compensation paid form with a legally-binding eSignature right on your iPhone or iPad. Set it up on your device to conclude contracts and manage forms from anyplace 24/7.

Follow the step-by-step guide to eSign your statement of compensation paid form on iOS devices:

  • 1.Open the App Store, find the airSlate SignNow app by airSlate, and install it on your device.
  • 2.Open the application, tap Create to upload a template, and select Myself.
  • 3.Choose Signature at the bottom toolbar and simply draw your signature with a finger or stylus to eSign the sample.
  • 4.Tap Done -> Save right after signing the sample.
  • 5.Tap Save or utilize the Make Template option to re-use this document later on.

This method is so simple your statement of compensation paid form is completed and signed within a couple of taps. The airSlate SignNow application works in the cloud so all the forms on your mobile device are kept in your account and are available any time you need them. Use airSlate SignNow for iOS to improve your document management and eSignature workflows!

How to Sign a PDF on Android How to Sign a PDF on Android

How to fill out and sign documents on Android

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Follow the step-by-step guidelines to eSign your statement of compensation paid form on Android:

  • 1.Go to Google Play, find the airSlate SignNow app from airSlate, and install it on your device.
  • 2.Log in to your account or register it with a free trial, then upload a file with a ➕ button on the bottom of you screen.
  • 3.Tap on the uploaded document and choose Open in Editor from the dropdown menu.
  • 4.Tap on Tools tab -> Signature, then draw or type your name to eSign the form. Fill out empty fields with other tools on the bottom if necessary.
  • 5.Utilize the ✔ button, then tap on the Save option to end up with editing.

With an intuitive interface and total compliance with main eSignature standards, the airSlate SignNow app is the best tool for signing your statement of compensation paid form. It even works without internet and updates all form modifications once your internet connection is restored and the tool is synced. Complete and eSign documents, send them for approval, and create re-usable templates whenever you need and from anyplace with airSlate SignNow.

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