Fillable Form Wcb-7 - Certificate Authorizing Release Of Unemployment Information printable pdf download

Form Wcb-7 - Certificate Authorizing Release Of Unemployment Information

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CERTIFICATE AUTHORIZING

RELEASE OF UNEMPLOYMENT INFORMATION

STATE OF MAINE

WORKERS' COMPENSATION BOARD

27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027

PART I (COMPLETED BY REQUESTOR)

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:

PART II (COMPLETED BY EMPLOYEE)

I, ____________________________________, understand that the information in my unemployment

compensation file(s) is confidential under 26 M.R.S.A. §1082(7), of the Maine Revised Statutes.

However, I waive my right to confidentiality and authorize the Workers’ Compensation Board to

obtain and release that information, pertaining to the benefit year ending ____/____/____, or calendar

period from ________________ through __________________ to the following:

Name:

___________________________________________

Title:

___________________________________________

Address:

___________________________________________

I understand that I may also request a copy of this information be sent to me. A copy of this

waiver/consent is acceptable.

Signature:_________________________

Date:_____________________

PART III (COMPLETED BY THE WORKERS’ COMPENSATION BOARD)

Unemployment information sent to the requestor on

__________________________________.

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-7 (eff. 01/1/13)

Form Wcb-7 - Certificate Authorizing Release Of Unemployment Information

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