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EMPLOYER’S FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE 

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REASON FOR REPORT (check all that apply)

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EMPLOYER
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(check one)  INSURER  THIRD PARTY ADMINISTRATOR (TPA)  SELF-ADMINISTERED EMPLOYER

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EMPLOYEE
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CLAIM INFORMATION
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PREPARER INFORMATION
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THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES, OR ACTIVITIES.
THIS FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS’ COMPENSATION BOARD, ADA COORDINATOR, TELEPHONE: 1-888-801-9087
OR TTY Maine Relay 711.
WCB-1 (eff. 1/1/13)