Memorandum Of Payment Form
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11. REVISION DATE:
2. WCB FILE NUMBER
MEMORANDUM OF PAYMENT
_____/_____/_____
(if known):
MM
DD
YYYY
EMPLOYEE
3. EMPLOYEE LAST NAME:
4. FIRST NAME:
5. MI.:
6. SOCIAL SECURITY NUMBER (last 4 digits):
XXX-XX-
7. STREET/P.O. BOX MAILING ADDRESS:
8. CITY:
9. STATE:
10. ZIP:
11. HOME PHONE NUMBER:
(
)
12. DATE OF INJURY:
13. SPECIFIC INJURY OR ILLNESS:
14. BODY PARTS (S) AFFECTED:
_____/_____/_____
MM
DD YYYY
EMPLOYER
15. INSURER FILE NUMBER:
16. EMPLOYER NAME:
17. EMPLOYER MAILING ADDRESS AND PHONE NUMBER:
18. INSURER NAME:
19.INSURER MAILING ADDRESS AND PHONE NUMBER:
NOTICE TO EMPLOYEE
20. YOUR EMPLOYER/INSURER IS REQUIRED TO FILE THIS WORKERS’ COMPENSATION FORM UPON PAYMENT OF A LOST TIME WORK-RELATED INJURY. PAYMENT
IS MADE FOR THE FOLLOWING REASON:
A.
YOUR CLAIM IS ACCEPTED.
B.
THIS IS A VOLUNTARY PAYMENT PENDING INVESTIGATION.
C.
THIS IS A MANDATORY PAYMENT PURSUANT TO RULE 1.1. AMOUNT PAID $ ________________. PERIOD COVERED BY MANDATORY PAYMENT:
FROM (DATE CLAIM MADE)
_____/_____/_____ THROUGH (DATE NOTICE OF CONTROVERSY FILED AND BENEFITS PAID)
______/_____/_____
MM
DD
YYYY
MM
DD
YYYY
21. TYPE OF PAYMENT:
22. FIRST DAY OF COMPENSABILITY AFTER
WAITING PERIOD WAS MET:
A.
WEEKLY COMPENSATION
B.
SPECIFIC LOSS: _________ WEEKS
_____/_____/_____
C.
OTHER (EXPLAIN): ___________________________________________________________________________
MM
DD
YYYY
23. DATE OF INCAPACITY:
_____/_____/_____
24. DATE CHECK MAILED:
25. AVERAGE WEEKLY WAGE:
26. CURRENT WEEKLY COMPENSATION RATE:
MM
DD
YYYY
TOTAL
PARTIAL
_____/_____/_____
$
$
MM
DD
YYYY
DATE EMPLOYER NOTIFIED
OF INCAPACITY:
_____/_____/_____
(IF VARYING RATES ARE BEING PAID, ENTER
MM
DD
YYYY
THE WORD “VARYING”)
27. IS THIS AN APPORTIONMENT CLAIM?
YES
NO
IF YES, ANSWER THE FOLLOWING:
OTHER DATE(S) OF INJURY INVOLVED: ______________________________________________________________________________________________________
OTHER INSURER(S) INVOLVED: ____________________________________________________________________________________________________________
EXPLAIN THE TERMS OF THE APPORTIONMENT: _____________________________________________________________________________________________
____________________________________________________________
28. COMMENTS:
ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS’ COMPENSATION BOARD’S REGIONAL OFFICES
AUGUSTA
BANGOR
CARIBOU
LEWISTON
PORTLAND
1037 FOREST AVE, STE 11
24 STONE ST, STE 102
106 HOGAN RD
ONE VAUGHN PL
36 MOLLISON WAY
AUGUSTA, ME
BANGOR, ME
43 HATCH DR, STE 110
LEWISTON, ME
PORTLAND, ME
04330-5220
04401-5638
CARIBOU, ME 04736
04240-7777
04103-3382
(207) 287-2308
(207) 941-4550
(207) 498-6428
(207) 753-7700
(207) 822-0840
1-800-400-6854
1-800-400-6856
1-800-400-6855
1-800-400-6857
1-800-400-6858
29. PREPARER NAME (TYPE OR PRINT):
30. TELEPHONE NUMBER:
31. DATE MAILED:
(
)
E-MAIL ADDRESS:
TOLL-FREE NUMBER:
_____/_____/_____
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-3 (eff. 1/1/13)
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