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FORMS
Most forms are fillable PDF files. Please note that you will need to download the fillable PDF form for the electronic signature feature.
These revised forms are effective as of June 1, 2026 and will be required as of September 1, 2026.
| Form # | Description |
|---|---|
| WCB-2 | Wage Statement |
| WCB-2B | Fringe Benefits Worksheet |
| WCB-2.1 | Wage Statement COMPARABLE WAGES (optional form) (PDF) |
| WCB-3 | Memorandum of Payment |
| WCB-3A | Memorandum of One-Time Payment (optional form) |
| WCB-4D | Discontinuance of Compensation |
| WCB-4M | Modification of Compensation |
| WCB-8 | Certificate of Discontinuance or Reduction of Compensation Pursuant to 39-A M.R.S.A. §205(9)(B)(1) |
| WCB-10 | Lump Sum Settlement |
| WCB-11A | Statement of Compensation Paid |
| WCB-11B | Statement of Compensation Paid (with instructions) |
Forms Training Mini-Manual (forms effective 6-1-26)(PDF)
All Forms
| Form # | Description |
|---|---|
| M-1 | Diagnostic Medical Report (Word or Fillable PDF) (Updated 11-14-23) |
| M-2 | Request for Independent Medical Examination |
| WCB-1 | Employer's First Report of Occupational Injury or Disease |
| WCB-2 | Wage Statement (Updated 4-1-25) (PDF) Word version |
| WCB-2 | Wage Statement (Updated 4-1-25) (Excel .xlsx Version) |
| WCB 2.1 | Wage Statement COMPARABLE WAGES (optional form) (PDF) |
| WCB-2A | Schedule of Dependent(s) and Filing Status Statement (Updated 9-27-23) |
| WCB-2B | Fringe Benefits Worksheet (Updated 9-3-20) |
| WCB-2C | Application for Waiver |
| Application for Waiver Instructions (PDF) | |
| WCB-3 | Memorandum of Payment (Updated 4-1-25) Word version |
| WCB-4A | Consent Between Employer and Employee (Updated 12-4-23) *Note: download the form to use the electronic signature feature. |
| WCB-4D | Discontinuance of Compensation (Updated 4-1-25) Word version |
| WCB-4M | Modification of Compensation (Updated 4-1-25) Word version |
| WCB-6 | Certificate Authorizing Release of Benefit Information (Updated 9-23-20) |
| WCB-7 | Certificate Authorizing Release of Unemployment Information (Updated 10-9-25) |
| WCB-8 | Certificate of Discontinuance or Reduction of Compensation Pursuant to 39-A M.R.S.A. §205(9)(B)(1) (Updated 4-1-25) Word version |
| WCB-9 | Notice of Controversy (Updated 12-4-23) |
| WCB-10 | Lump Sum Settlement (Updated 9-14-20) *Note: download the form to use the electronic signature feature. |
| WCB-11A* | Statement of Compensation Paid (Updated 4-1-25) Word version |
| WCB-11B* | Statement of Compensation Paid (with instructions on the form) (Updated 4-1-25) Word Version |
| WCB-25 | Motion for Award of Fees and Disbursements |
| WCB-90 | Workers' Compensation Board Notice to Employees (POSTER) (Revised 4-28-26) |
| WCB-120 | Petition for Review of Incapacity |
| WCB-121 | Employee Petition for Review of Incapacity and Request for Provisional Order |
| WCB-122 | Petition to Determine Average Weekly Wage |
| WCB-140 | Petition for Award of Compensation (Updated 10-11-23) |
| WCB-150 | Petition for Award of Compensation - Fatal |
| WCB-160 | Petition for Award of Compensation - Occupational Disease Law |
| WCB-170 | Petition for Restoration (Updated 10-11-23) |
| WCB-171 | Petition for Reinstatement (Updated 10-11-23) |
| WCB-180 | Petition to Determine Extent of Permanent Impairment |
| WCB-190 | Petition for Payment of Medical and Related Services |
| WCB-190A | Provider's Petition for Payment of Medical and Related Services |
| WCB-195 | Petition to Remedy Discrimination |
| WCB-205 | Work Search Record |
| WCB-206 | Employee Expense Form (Updated 4-29-26 with new CRO address) |
| WCB-211 | Petition to Terminate Benefit Entitlement |
| WCB-213 | Petition for Extension of Benefits Due to Extreme Financial Hardship Pursuant to 39-A M.R.S.A. §213(1) |
| WCB-213A | Petition for Review of Extended Benefits Awarded Due to Extreme Financial Hardship Pursuant to 39-A M.R.S.A. §213(1)(B) |
| WCB-220 | Limited Release of Medical/Health Care Information (Updated 10-23-23) |
| WCB-220-A | Limited Release of Medical/Health Care Information Related to Psychological Matters (Updated 10-23-23) |
| WCB-220-B | Limited Release of Medical/Health Care Information Related to Substance Abuse (Updated 10-23-23) |
| WCB-220-C | Limited Release of Medical/Health Care Information Related to HIV/AIDS and Sexually Transmitted Diseases (updated 10-23-23) |
| WCB-220-R | Revocation of Limited Release of Medical/Health Care Information (Updated 10-23-23) |
| WCB-230 | Employment Status Report |
| WCB-231 | Employee's Return to Work Report Pursuant to 39-A M.R.S.A. §308(1) |
| WCB-231A | Employee's Return to Work Report Pursuant to 39-A M.R.S.A. §205(9)(B) |
| WCB-240 | Notice of Intent to Appeal |
| WCB-250 | Request for Expedited Proceeding (Updated 12-4-23) |
| WCB-260 | Application for Predetermination of Independent Contractor Status to Establish Conclusive Presumption |
| WCB-262 | Application for a Certificate of Independent Status- Wood Harvester |
| WCB-267 | Independent Contractor Statement - Online fillable. (Printable version available here) |
| WCB-282 | Complaint for Audit |
| WCB-320 | Application for Evaluation Employment Rehabilitation Services Pursuant to 39-A M.R.S.A. §217(1) (Updated 10-11-23) |
| WCB-322 | Application for Wage Credit Employment Rehabilitation Fund |
| WCB-400 | Complaint for Penalties Pursuant to 39-A §205(3) |
| WCB-410 | Complaint for Penalties Pursuant to 39-A §205(4) |
| WCB-420 | Petition for Forfeiture Pursuant to 39-A §324(2) |
| Joint Scheduling Memorandum (Word or Fillable PDF) | |
| In Person Hearing Motion and Memo (both are Word documents) |
*Based on user feedback two versions of the WCB-11 form are available. WCB-11A is the standard form. WCB-11B is the same form, but includes basic instructions on the form. Users may file either version based on their preference.
If you have questions, please contact Debi Hutchins.