NOTICE OF WORKERS’ COMPENSATION
INSURANCE, WCB-1A
Reporting Requirements
The insurer must file a Notice of Workers’ Compensation Insurance
(1AWC), WCB-1A, to report the issuance, renewal, endorsement, cancellation
and/or reinstatement of an employer’s workers’ compensation
insurance policy.
The insurer must file a Notice of Workers’ Compensation Insurance
with the Workers’ Compensation Board (Central Office) within 14
days after issuance, renewal, reinstatement or endorsement of an employer’s
workers’ compensation insurance policy. The insurer must
mail a copy of the Notice of Workers’ Compensation Insurance to
the employer within 14 days after the issuance, renewal, reinstatement
or endorsement of the workers’ compensation insurance policy.
The insurer must mail a Notice of Workers’ Compensation Insurance
to the Workers’ Compensation Board and to the employer at least
thirty (30) days prior to cancellation of an employer’s workers’ compensation
insurance policy.
Distribution
The Notice of Workers’ Compensation Insurance (1AWC), WCB-1A,
is to be distributed as follows:
Original Send
the original Notice of Workers’ Compensation Insurance to the
Workers’ Compensation Board at the following address:
State
of Maine
Workers’ Compensation
Board
27
State House Station
Augusta,
Maine 04333-0027
Copy 1 Mail
one copy of the Notice of Workers’ Compensation Insurance to the
employer.
Copy 2 Keep
one copy of the Notice of Workers’ Compensation Insurance for your
records.
Form Filing Violations
Failure to file any Board-prescribed forms within established time frames
is a violation of §360(1). Violations will 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.
INSTRUCTIONS FOR COMPLETING
NOTICE OF WORKERS’ COMPENSATION INSURANCE, WCB-1A
- Maine Employer (DBA)
Enter the employer's primary business name. If the employer does
business under any other name(s), please provide the name(s).
- Address
Enter the address where the employer receives mail (street/P.O. Box,
city, state, and zip code).
- Owner's Name
Enter the name(s) of the person(s) or entity who own(s) the business
listed on line 1.
- Address
Enter the address where the owner receives mail (street/P.O. Box, state,
city, and zip code)
- UIAN (State Tax #)
Enter the employer’s Unemployment Insurance Account Number. The
Workers’ Compensation Board uses the Unemployment Insurance Account
Number to identify employers. The Maine Department of Labor assigns
this 10‑digit number to all employers who are liable for contributions
for unemployment insurance. If the employer is not liable for contributions
to unemployment insurance, the employer will not have a UIAN and should,
therefore, call the Coverage Unit of the Workers’ Compensation
Board to ask for assignment of an identification number.
- FEIN (Federal Tax #)
Enter the employer’s Federal Employer Identification Number. This
number is assigned by the Internal Revenue Service (IRS) and is used
to report all monies paid to the IRS. Some employers use their
Social Security number to report monies paid to the IRS. If this
is the case, then enter the employer’s Social Security number in
this box.
- All Locations with Maine Coverage
If the policy listed on line 13 covers more than one business location
for the employer, provide a list of all those physical locations. Use
an additional sheet of paper if necessary. Also provide the business
name(s) for each location when the name is different from the primary
business name listed on line 1.
- Nature of Business Covered by this Policy
Enter a brief description of the primary type of business performed
by the employer listed on line 1 (construction, well drilling, health
care, etc.).
- Name of Insurance Carrier
Enter the name of the insurance company providing workers' compensation
insurance to the employer listed on line 1.
- NCCI #
Enter the insurer’s NCCI number. This number is assigned
by the National Council on Compensation Insurance, Inc. (NCCI) and may
be obtained from the Bureau of Insurance.
- Address
Enter the address where the employer receives mail (street/P.O. Box,
city, state and zip code).
- Type of Policy (please indicate)
- If the employer (line 1) was not previously insured by the insurer
(line 9), check “New.”
- To report the renewal of a policy previously covered by the insurer
(line 9), check “Renewal.”
- To report the reinstatement of a policy previously cancelled by the
same insurer (line 9), check “Reinstatement.” (If
you check “Reinstatement,” you also need to complete boxes 18
and 19.)
- To report any change(s) to the current policy, check “Endorsement.” (If
you check “Endorsement,” you must also complete boxes 20,
21, and 22.)
- To report the cancellation of an active policy prior to the expiration
date reported on line 14, check “Cancellation.” (If
you check “Cancellation,” you must also complete boxes
15, 16, and 17.) If termination occurs on the policy
expiration date, this cancellation notice does not need to be sent
to the Workers’ Compensation Board.
- Policy Number
Enter the number assigned to the current workers' compensation policy
for the employer (line 1).
- Date of Coverage
From: ________________
Enter the effective date (month, day, year) of the current workers’ compensation
insurance policy for the employer (line 1).
To: ________________
Enter the expiration date (month, day, year) of the current workers’ compensation
insurance policy for the employer (line 1).
CANCELLATION NOTICE
This information is to be completed only if the policy on line 13 is
cancelled prior to the expiration date reported on line 14. If
this section is completed, a copy of this form must be sent to the Workers'
Compensation Board and to the employer listed on line 1 at least thirty
(30) days prior to the effective date (line 16).
- Date of Mailing
Enter the date (month, day, year) that this form is sent (mail, fax,
etc.) to the Workers' Compensation Board and to the employer (line 1).
- Please note that coverage has been cancelled as of
Enter the effective date (month, day, year) of this policy cancellation.
- Reason for Cancellation
Enter a brief description of the reasons(s) for this policy cancellation.
If the cancellation occurs on policy expiration date, cancellation
notice does not need to be sent to the Board.
REINSTATEMENT
This information is to be completed only when the policy listed on line
13 is reinstated after a cancellation prior to the policy expiration
date reported on line 14.
- Date of Mailing
Enter the date (month, day, year) that this form is sent (mail, fax,
etc.) to the Workers' Compensation Board and to the employer (line 1).
- This is to inform you of the withdrawal of the cancellation notice,
which was to have been effective on
Enter the effective date (month, day, year) of the policy reinstatement. (This
date must be the same as the effective date of cancellation reported
on line 16.)
ENDORSEMENT
This information is to be completed only when there is a change/amendment
to the policy listed on line 13.
- Date of Mailing
Enter the date (month, day, year) that this form is sent (mail, fax,
etc.) to the Workers’ Compensation Board and to the employer (line 1).
- Effective Date
Enter the effective date (month, day, year) of any change(s) to the
policy.
- It is agreed that as of the effective date hereof, the policy is
amended as follows
Enter a brief description of any change(s) to the policy.
- Preparer Name and Title
Enter the name and title of the person completing this form.
- Telephone Number
Enter the telephone number (area code and telephone number) of the authorized
contact person (line 23).
- Date Sent to WCB
Enter the date (month, day, year) that this form is sent to the Workers'
Compensation Board.
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