Skip Maine state header navigation

Agencies | Online Services | Help

Skip First Level Navigation | Skip All Navigation

Home >Board Forms> Employee's Return to Work Instructions

EMPLOYEE’S RETURN TO WORK REPORT, WCB-231

The employer or insurer (which can sometimes be one and the same) mails the Employee’s Return to Work Report to the employee when filing the Memorandum of Payment, WCB-3, pursuant to 39-A M.R.S.A.§205(7). The employee completes boxes 20 and 21 of this form and files it with the employer (box 2) and the insurer (box 4) within seven days of his or her return to work with a new or different employer.

The Employee’s Return to Work Report is a four-part form. The distribution is as follows:

Copy 1 to the Workers’ Compensation Board.
Copy 2 to the Employee.
Copy 3 to the Insurer.
Copy 4 to the Employer.

INSTRUCTIONS FOR COMPLETING EMPLOYEE’S
RETURN TO WORK REPORT, WCB-231

Boxes 1 Through 17 Are Completed By The Employer/Insurer

  1. Insurer File Number
    This box is provided for use by the insurer. If the insurer file number is known at the time of filing the Employee's Return to Work Report, enter it here. The Board will record it for reference.
  2. Employer Name
    Enter the employer name as it was entered in box 10 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
  3. Employer Mailing Address or Phone Number
    Enter the address where the employer receives mail. Also enter the employer's phone number, including area code.
  4. Insurer Name
    Enter the name of the employer's workers' compensation insurer, self‑insured, or third‑party administrator if there is one.
  5. Insurer Mailing Address
    Enter the insurer, self‑insured, or third‑party administrator's mailing address.
  6. Social Security Number
    Enter the employee's social security number.
  7. WCB File Number
    If the preparer knows this number, enter it here. Doing so will speed up processing this form.
  8. Employee Last Name
    Enter the employee’s last name as entered in box 27 of the Employer’s First Report of Occupational Injury or Disease, WCB-1.
  9. First Name
    Enter the employee’s first name as entered in box 28 of the Employer’s First Report of Occupational Injury of Disease, WCB-1.
  10. M.I.
    Enter the employee’s middle initial as entered in box 29 of the Employer’s First Report of Occupational Injury or Disease, WCB-1.
  11. Address – Street and Number
    Enter the employee’s mailing address.
  12. City
    Enter the city of employee's mailing address.
  13. State
    Enter the state of employee's mailing address.
  14. Zip
    Enter the zip code of the employee’s mailing address.
  15. Home
    Enter the employee’s home telephone number, including area code.
  16. Date of Injury
    Enter the date of injury. This date should be the same as box 42 of the Employer’s First Report of Occupational Injury or Disease, WCB-1.
  17. Description of Injury
    Enter a complete description of the injury or illness.

Notice to Employer/Insurer

  1. This section notifies the employer/insurer when to send this form to the employee.

Notice to Employee

  1. This section notifies the employee or his or her responsibilities.

Boxes 20 and 21 Are Completed By The Employee.

  1. Complete this section, supplying the following information.
    A. Name, address, and telephone number(s) of each new employee.
    B. Date(s) of hire.
    C. Attach verification of income or list anticipated income with each new employer.
    D. Use this space to provide any comments.
  2. Sign and date this form to certify that the information is truthful and accurate.

Return to WCB Forms