Form WCB-231 "Employee's Return to Work Report" - Maine

Form WCB-231 or the "Employee's Return To Work Report" is a form issued by the Maine Workers' Compensation Board.

The form was last revised in January 1, 2013 and is available for digital filing. Download an up-to-date Form WCB-231 in PDF-format down below or look it up on the Maine Workers' Compensation Board Forms website.

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Download Form WCB-231 "Employee's Return to Work Report" - Maine

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EMPLOYEE'S RETURN TO WORK 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/INSURER
THE EMPLOYER/INSURER SHALL SEND THE EMPLOYEE'S RETURN TO WORK REPORT TO THE EMPLOYEE WHEN FILING THE
MEMORANDUM OF PAYMENT PURSUANT TO 90 MAR 351 CH. 8. §17.
19.
NOTICE TO EMPLOYEE
IF YOU RETURN TO WORK WITH A NEW EMPLOYER, COMPLETE BOXES 20 AND 21 AND FILE COPIES OF THIS REPORT WITH
THE BOARD AND YOUR PREVIOUS EMPLOYER AT THE ADDRESSES LISTED ABOVE WIITHIN 7 DAYS PURSUANT TO 39-A
M.R.S.A. §308(1).
FAILURE TO COMPLETE AND RETURN THIS REPORT MAY AFFECT YOUR WORKERS' COMPENSATION INDEMNITY BENEFITS.
PART II (COMPLETED BY THE EMPLOYEE)
20. COMPLETE THE FOLLOWING INFORMATION (USE REVERSE SIDE IF NECESSARY).
A.
NEW EMPLOYER NAME: _______________________________ TELEPHONE: ________________________________
ADDRESS: _______________________________________________________________________________________
CITY: ____________________________________ STATE: _____________ ZIP: _____________________________
B.
DATE OF HIRE: ___________________________________________
C.
ATTACH VERIFICATION OF INCOME OR LIST ANTICIPATED INCOME: ______________________________________
__________________________________________________________________________________________________
D.
COMMENTS:
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-231 (eff. 1/1/13)
EMPLOYEE'S RETURN TO WORK 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/INSURER
THE EMPLOYER/INSURER SHALL SEND THE EMPLOYEE'S RETURN TO WORK REPORT TO THE EMPLOYEE WHEN FILING THE
MEMORANDUM OF PAYMENT PURSUANT TO 90 MAR 351 CH. 8. §17.
19.
NOTICE TO EMPLOYEE
IF YOU RETURN TO WORK WITH A NEW EMPLOYER, COMPLETE BOXES 20 AND 21 AND FILE COPIES OF THIS REPORT WITH
THE BOARD AND YOUR PREVIOUS EMPLOYER AT THE ADDRESSES LISTED ABOVE WIITHIN 7 DAYS PURSUANT TO 39-A
M.R.S.A. §308(1).
FAILURE TO COMPLETE AND RETURN THIS REPORT MAY AFFECT YOUR WORKERS' COMPENSATION INDEMNITY BENEFITS.
PART II (COMPLETED BY THE EMPLOYEE)
20. COMPLETE THE FOLLOWING INFORMATION (USE REVERSE SIDE IF NECESSARY).
A.
NEW EMPLOYER NAME: _______________________________ TELEPHONE: ________________________________
ADDRESS: _______________________________________________________________________________________
CITY: ____________________________________ STATE: _____________ ZIP: _____________________________
B.
DATE OF HIRE: ___________________________________________
C.
ATTACH VERIFICATION OF INCOME OR LIST ANTICIPATED INCOME: ______________________________________
__________________________________________________________________________________________________
D.
COMMENTS:
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-231 (eff. 1/1/13)
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