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Fill and Sign the Statement of Compensation Paid Form

Fill and Sign the Statement of Compensation Paid Form

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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)

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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

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How to Sign a PDF Using Google Chrome How to Sign a PDF Using Google Chrome

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How to Sign a PDF in Gmail How to Sign a PDF in Gmail How to Sign a PDF in Gmail

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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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  • 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

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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.
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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.

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