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The initial Statement of Compensation Paid, Interim Report (WCB-11) shall be filed with the Board within 195 days of the date of an injury where indemnity payments have been made, and as a Final Report when no further payments are anticipated.
Subsequent Statements of Compensation Paid (WCB-11) shall thereafter be filed with the Board within fifteen (15) days of each anniversary date of an injury when payments of any type have been made since the previous Statement of Compensation Paid (WCB-11).
The Statement of Compensation Paid (WCB-11) is required when only medical payments are made subsequent to the filing of a Final Report.
There is no requirement to file the Statement of Compensation Paid on claims when payments are made for medical only services and no indemnity was ever paid on the claim.
The Statement of Compensation Paid is a four-part form that is to be distributed as follows:
Copy (1) Workers Compensation Board via e-mail, via fax, or via standard mail at:
State of Maine
Workers' Compensation Board
27 State House Station
Augusta, Maine 04333-0027
Copy (2) Employee
Copy (3) Insurer
Copy (4) Employer
Failure to file any Boardprescribed forms within established time frames is a violation under §360(1). Violations may result in the filing of complaints with the Abuse Investigation Unit. The Abuse Investigation Unit will process the complaint in the manner set forth in WCB Rule 15.9.
Identifying Information
Enter the claim administrator claim number as it was entered in box 21 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Enter the employer name as it was entered in box 10 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Enter the employer mailing address and phone number as it was entered in boxes 11-15 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Enter the insurer name as it was entered in box 19 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Enter the insurer mailing address as it was entered in boxes 22-25 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Enter the employee's ID # as it was entered in box 31 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Enter the jurisdiction claim number assigned by the State of Maine to identify this claim.
Enter the employee's last name as it was entered in box 27 of the Employer's First Report of Occupational Injury or Disease, WCB1.
Enter the employee's first name as it was entered in box 28 of the Employer's First Report of Occupational Injury or Disease, WCB1.
Enter the employee's middle initial as it was entered in box 29 of the Employer's First Report of Occupational Injury or Disease, WCB1.
Enter the number and street of the employees mailing address as it was entered in box 33 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Enter the city of the employee's mailing address as it was entered in box 34 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Enter the state of the employee's mailing address as it was entered in box 35 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Enter the zip code of the employee's mailing address as it was entered in box 36 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Enter the employee's home telephone number as it was entered in box 30 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Enter the date of injury or illness as it was entered in box 42 of the Employer's First Report of Occupational Injury or Disease, WCB1.
Enter a brief description of the injury or illness.
Check the box that describes the type of report being filed.
If you have received information that the injury is permanent, check Yes, otherwise, check No.
B. If Yes, what is the Permanent Impairment Rating? ____% Not Yet Available
If the percentage of whole body impairment is known, enter it on the line provided. Otherwise, check Not Yet Available.
Medical enter the sum of medical benefits paid for this claim.
Weekly Compensation enter the sum of indemnity benefits paid for this claim (dependent benefits, specific loss benefits and mandatory payments are considered weekly compensation benefits). This amount must match the sum of the amount paid on all WCB-4, WCB-4A and mandatory Memorandum of Payment forms and/or the sum of the Compensation Payment to Date of Certificate and Compensation to be Paid for 21-Day Period on all WCB-8 forms.
Permanent Impairment enter the sum of permanent impairment benefits paid for this claim (pre 1993 claims only).
Rehabilitation Expense enter the sum of rehabilitation expenses paid for this claim.
Lump Sum Settlement enter the amount approved by Board Hearing Officer of any lump sum settlement.
Death Benefit/Funeral Expense enter the sum of funeral expenses paid for this claim (cannot exceed $7,000.00).
Legal Expense (Employee Related) enter the sum of the claimants legal expenses paid for this claim.
Legal Expense (Employer Related) enter the sum of the employers legal expenses paid for this claim.
Other enter the sum of all other payments not otherwise reported for this claim.
Total Paid - enter the total amount paid for all categories.
EXAMPLE: The following has been paid on a claim:
Payments to physicians $ 500.00
Payments to hospitals $1,000.00
Temporary Total Disability $2,000.00
A $1,000.00 deductible has been recovered from the employer.
The amounts shown in box 20 should be as follows:
Medical $1,500.00
Weekly Compensation $2,000.00
Preparer Information
Enter the preparer's name and title.
Enter the preparer's telephone number, including area code.
Enter the date (month, day, year) this form is sent (mail, fax, email) to the Workers Compensation Board. When revising a previously filed form, put a line through the original "Date Sent to WCB" date and note the revision date.