WAGE STATEMENT, WCB-2
Reporting Requirements
The employer or insurer (which can sometimes be one and the same) must file a Wage Statement to report an injured employee's federal wages for the 52 weeks immediately preceding the work‑related injury (See Section 102.4 of the Maine Workers’ Compensation Act of 1992 for exceptions).
A Wage Statement must be filed with the Workers' Compensation Board (Central Office) within 30 days after the employer receives notice or has knowledge of a claim for compensation (box 28 of the Memorandum of Payment, WCB‑3, or box 20 of the Notice of Controversy, WCB‑9).
Distribution
A Wage Statement is a four‑part form that is to be distributed as follows:
Copy 1 to the Workers’ Compensation Board at the following address:
State of Maine
Workers' Compensation Board
27 State House Station
Augusta, Maine 04333-0027
Copy 2 to the Employee.
Copy 3 to the Insurer.
Copy 4 to the Employer.
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 WAGE STATEMENT, WCB-2
Identifying Information
- Insurer File Number
This box is provided for use by the insurer. If the insurer file number is known at the time the Wage Statement is filed, enter it here. The Board will record it for reference.
- Employer Name
Enter the employer name as it appears on the employer’s workers’ compensation insurance policy.
- Employer Mailing Address and Phone Number
Enter the address where the employer receives mail. Also enter the employer’s phone number, including area code.
- Insurer Name
Enter the name of the employer’s workers’ compensation insurance company. If the employer is self-insured or group self-insured, indicate this and provide the name of the third-party administrator if there is one.
- Insurer Mailing Address
Enter the insurer, self-insured, or third-party administrator’s mailing address.
- Social Security Number
Enter the employee's social security number.
- WCB File Number
If the preparer knows this number, enter it here. Doing so will speed up processing this form.
- 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.
- First Name
Enter the employee's first name as entered in box 28 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
- 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.
- Address – Number and Street
Enter employee's mailing address.
- City
Enter city of employee's mailing address.
- State
Enter state of employee's mailing address.
- Zip
Enter zip code of employee's mailing address.
- Home Phone Number
Enter employee's home telephone number, including area code.
- 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.
- Description of Injury
Enter a complete description of the injury.
- Does Employee Work for Another Employer?
Check "Yes" or "No." If "Yes," the employer for whom the employee worked at the time of the injury is required to file the Wage Statement(s), WCB‑2, from the employee's other employer(s).
- Does the employee receive fringe benefits that may stop while on Workers' Compensation?
Check "Yes" or "No." If the employee receives any fringe or other benefit paid by the employer that does not continue during the disability, that amount must be included for purposes of determining the employee's average weekly wage. (If the employee's 80 percent net average weekly wage is less than two‑thirds of the statewide average weekly wage, the employee is entitled to inclusion of fringe benefits. This inclusion, however, should not increase the employee's rate beyond two‑thirds of the statewide average weekly wage.)
Wage Information
- Weekly Wages
Enter the "week ending" date and "gross earnings" for the 52 weeks preceding the injury. Week 52 is the week prior to the injury if inclusion of the wages from the week in which the injury occurred would reduce the average weekly wage. Week 1 is one year preceding the injury.
A legible copy of the employer's record of payments containing the same or equivalent information is acceptable in place of box 20.
If the employee did not work for the employer for 52 weeks preceding the injury, refer to Section 102(4) of the Act to determine the proper information to file.
- Total Earnings
Add weeks 1 through 52. When the employer's record of payments is used to provide the information requested in box 20, the "Total Earnings" from that record of payments must be entered in box 21.
- Gross Average Weekly Wage
Enter the average weekly wage. (Compute this amount in accordance with Section 102.4 of the Maine Workers’ Compensation Act of 1992.)
Preparer Information
- Preparer Name and Title
Type or print the preparer's name and title.
- Telephone Number
Enter the preparer's telephone number, including area code.
- Date Mailed
Enter the actual date this document is mailed.
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