Fillable EMPLOYERS FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE (National American Insurance Company)

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EMPLOYERS FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE (National American Insurance Company)

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EMPLOYER’S FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE
:&%),/(180%(5LINQRZQ:
D26+$&$6(180%(5LIDSSOLFDEOH:
REASON FOR REPORT (check all that apply)
D/2677,0(21(25025('$<6E:$6(03/2<((3$,')25ò'$<25025(21'$<2),1-85<" <(6 12
/267($51,1*6%8712/2677,0(0(',&$/+($/7+&$5( )$7$/,7<'$7(2)'($7+BBBBBBBBBBBBBBB
00''<<<<
D2&&83$7,21$/',6($6(E'$7(2)/$67(;32685(BBBBBBBBBBBBBBBF'$7(2)',$*126,6$62&&83$7,21$//<5(/$7('BBBBBBBBBBBBBB
00''<<<<  00''<<<<
D&255(&735,255(3257E'$7(2)&255(&7,21BBBBBBBBBBBBBBB F'$7(&255(&7,216(1772:&%BBBBBBBBBBBBBBB 
00''<<<< 00''<<<<
EMPLOYER
67$7((03/2<(581(03/2<0(17
,1685$1&($&&2817180%(58,$1
)('(5$/(03/2<(5,'(17,),&$7,21180%(5)(,1
(03/2<(51$0(
675((732%2;0$,/,1*$''5(66
&,7<
67$7(
=,3
7(/(3+21(180%(5

35,0$5<%86,1(663(5)250('%<
(03/2<(5:+(5(,1-85<2&&855('
0$,/,1*$''5(66
',',1-85<25(;32685(2&&8521(03/2<(5¶635(0,6(6"
<(6
12
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,1-85('25(;326('
(check one)
INSURER
THIRD PARTY ADMINISTRATOR (TPA)
SELF-ADMINISTERED EMPLOYER
,1685$1&(73$&203$1<1$0(
32/,&<180%(5
,1685(5),/(180%(5
675((732%2;0$,/,1*$''5(66
&,7<
67$7(
=,3
7(/(3+21(180%(5

EMPLOYEE
/$671$0(
),5671$0(
0,
7(/(3+21(180%(5


62&,$/6(&85,7<180%(5

*(1'(5
0$/()(0$/(
675((732%2;0$,/,1*$''5(66
&,7<
67$7(
=,3
'$7(2)%,57+
BBBBBBBBBBBBBBB
00''<<<<
2&&83$7,21-2%7,7/(
'$7(2)+,5(
BBBBBBBBBBBBBBB
00''<<<<
:((./<:$*($77,0(2),1-85<

'2(6(03/2<((:25.)25$127+(5(03/2<(5"
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CLAIM INFORMATION
'$7(2),1-85<25,//1(66
BBBBBBBBBBBBBBB
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'$7((03/2<(5127,),('
BBBBBBBBBBBBBBB
00'' <<<<
'$7(2),1&$3$&,7<
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00''<<<<
'$7((03/2<(5127,),('
BBBBBBBBBBBBBBB
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7,0((03/2<((%(*$1:25.
HJDP
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7,0(2),1-85<HJSP
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'72:25."
<(6
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,)<(6*,9('$7(BBBBBBBBBBBBBBB
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63(&,),&,1-85<25,//1(66
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$//(48,30(170$7(5,$/625&+(0,&$/6(03/2<((:$6
86,1*:+(17+((9(172&&855('HJDFHW\OHQHWRUFKPHWDOSODWH
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:$6$&7,9,7<3$572)1250$/-2%'87,(6"<(612
+2:,1-85<25,//1(662&&855(''(6&5,%(7+(6(48(1&(2)(9(176$1',1&/8'($1<2%-(&762568%67$1&(6
7+$7',5(&7/<,1-85('250$'(7+((03/2<((,//HJZRUNHUVWHSSHGEDFNWRLQVSHFWZRUNDQG
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
PREPARER INFORMATION
35(3$5(51$0($1'7,7/(7<3(2535,17
7(/(3+21(180%(5

'$7(6(1772:&%
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00''<<<<
THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES, OR ACTIVITIES.
THIS FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS’ COMPENSATION BOARD, ADA COORDINATOR, TELEPHONE: 1-888-801-9087
OR TTY Maine Relay 711.
WCB-1 (eff. 1/1/13)
WAGE STATEMENT
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. WCB 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. DOES EMPLOYEE WORK CONCURRENTLY
FOR
ANOTHER EMPLOYER?
IF YES, GIVE NAME(S):____________________________
NOTE: THE EMPLOYER SHALL SUBMIT A WAGE
STATEMENT FOR EACH ADDITIONAL EMPLOYER.
YES
NO
19. DOES EMPLOYEE RECEIVE FRINGE BENEFITS THAT MAY STOP
WHILE
ON WORKERS’ COMPENSATION?
NOTE: THE EMPLOYER SHALL RECALCULATE THE AVERAGE
WEEKLY
WAGE IF/WHEN FRINGE BENEFITS CEASE (SEE RULE
1.5(2))
YES
NO
/,67*5266($51,1*6)25($&+:((.                                                 
WK
1
WEEK ENDING GROSS EARNINGS WK
19
WEEK ENDING
GROSS EARNINGS WK
37
WEEK ENDING
GROSS EARNINGS
2
20 38
3
21 39
4
22 40
5
23 41
6
24 42
7
25 43
8
26 44
9
27 45
10
28 46
11
29 47
12
30 48
13
31 49
14
32 50
15
33 51
16
34 :.2)
,1-85<
17
35 727$/
($51,1*6 
18
36 *5266$9(5$*(
:((./<:$*( 
23. COMMENTS:
24. PREPARER NAME (TYPE OR PRINT):
E-MAIL ADDRESS:
25. TELEPHONE NUMBER:
( )
TOLL-FREE NUMBER:
( )
26. 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 Workers’ Compensation Board. Telephone: 1-888-801-9087 or TTY Maine Relay 711.
WCB-2 (eff. 1/1/13)
SCHEDULE OF DEPENDENT(S) AND
FILING STATUS STATEMENT
STATE OF MAINE
WORKERS' COMPENSATION BOARD
STATION 27, AUGUSTA, MAINE 04333-0027
EMPLOYER/INSURER COMPLETES BOXES 1 TO 17
1. INSURER FILE NUMBER:
6. SOCIAL SECURITY NUMBER
;;;;;
7. WCB 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:
EMPLOYEE COMPLETES BOXES 18 TO 22
18. FEDERAL TAX FILING STATUS
SINGLE MARRIED/JOINT
SINGLE/HEAD OF HOUSEHOLD MARRIED/SEPARATE
19.
DEPENDENT(S)
DEPENDENT NAME(S)
(IF NONE, SO STATE)
RELATIONSHIP
(I.E., SPOUSE, DAUGHTER, SON)
DATE OF
BI
RTH
SOCIAL SECURITY
NUMBER
(IF NONE, SO STATE)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
20. PREPARER NAME AND TITLE (TYPE OR PRINT): 21. TELEPHONE NUMBER: 22. DATE MAILED:
THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES, OR ACTIVITIES.
THIS FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS’ COMPENSATION BOARD, ADA COORDINATOR,
TELEPHONE: 1-888-801-9087 OR TTY MAINE RELAY 711.
WCB-2A (eff. 1/1/13)
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EMPLOYERS FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE (National American Insurance Company)

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Completed 29 July 2021

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