Form Wcb-230 - Employment Status Report
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1EMPLOYMENT STATUS 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):
7. WCB FILE NUMBER:
XXX-XX-
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
ANY EMPLOYER REQUESTING A QUARTERLY REPORT MUST PROVIDE THE EMPLOYEE WITH THIS FORM AT LEAST 15 DAYS
PRIOR TO THE DATE ON WHICH THE REPORT IS DUE , PURSUANT TO 39-A M.R.S.A. §308(2).
19.
NOTICE TO EMPLOYEE
COMPLETE BOXES 20 AND 21AND RETURN THIS REPORT TO THE EMPLOYER LISTED ABOVE. FAILURE TO COMPLETE AND
RETURN THIS REPORT MAY AFFECT YOUR WORKERS' COMPENSATION INDEMNITY BENEFITS.
THIS REPORT IS DUE: ___________________________
THIS REPORT COVERS THE PERIOD FROM ________________________TO ____________________
PART II (COMPLETED BY THE EMPLOYEE)
20.
A. HAVE YOU BEEN EMPLOYED, CHANGED EMPLOYMENT OR PERFORMED ANY SERVICES FOR COMPENSATION
DURING THE PERIOD STATED IN THE ABOVE SECTION?
YES
NO
B.
IF YES, COMPLETE THE FOLLOWING FOR EACH EMPLOYER AND ATTACH VERIFICATION OF INCOME:
EMPLOYER NAME: ___________________________________ TELEPHONE: ________________________________
ADDRESS: _______________________________________________________________________________________
CITY: ____________________________________ STATE: _____________ ZIP: _____________________________
NATURE OF THE EMPLOYMENT OR SERVICES __________________________________________________________
EMPLOYED FROM: ______________________ TO ______________________
ARE YOU STILL EMPLOYED?
YES
NO
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-230 (eff. 1/1/13)
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Parent category: Business