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The claims administrator (CA) must file a Memorandum of Payment (MOP) with the Board (1) upon making the first payment of weekly compensation for incapacity due to occupational injury, disease, or death, (2) upon making the first payment of weekly compensation for specific loss benefits, (3) upon making a payment of compensation for permanent impairment (pre 1993 claims only), (4) upon making a payment of compensation pursuant to a decision of the Board, (5) upon making a payment of compensation pursuant to Rule 1.1(2), or (6) once indemnity benefits would otherwise be payable after the seven-day wait period is met for cases involving salary continuation.
A MOP must be sent to the Board on or before the 14th day payment is due under §205(2) and must be received at the Board by the 17th day (three mail days are provided for receipt by the Board where the form is sent via standard mail). Evidence of timely mailing is a rebuttable presumption to a determination of noncompliance under §360(1).
Compliance with the initial indemnity payment obligation exists when the check is mailed within the later of: 1) 14 days after the employers notice or knowledge of incapacity or 2) the first day of compensability plus 6 days.
If an employer continues to pay the employees salary, payments are deemed timely for purposes of compliance if made consistent with the employers usual payroll practice.
The employer and/or the CA must file the wage information (WCB-2 and WCB-2A) within 30 days of the first day of compensability.
The MOP is a four-part form that must 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
Closure of all MOPs other than those issued pursuant to Rule 1.1(3) is required. Closure occurs when one of the following actions is taken:
Failure to file any Board-prescribed 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 complaints in the manner set forth in Rule 15.9.
Failure to file a Notice of Controversy (denial) or pay benefits on or before the 14th day payment is due under §205(2) is a violation of Rule 1.1(1). This violation requires payment of benefits to the injured employee as set forth in Rule 1.1(2), which must be reported on a MOP, as required by Rule 1.1(3).
Failure to file a Notice of Controversy (denial) or pay benefits on or before 30 days after the 14th day payment is due under §205(2) requires a penalty payment to the injured employee, as set forth in §205(3).
| 1. | Revision Date: | ___/ | ___/ | ____ |
| MM | DD | YYYY |
If you are amending any information on this form that has already been filed with the parties involved (Board, employee, insurer, employer), enter the date (month, day, year) that this amended form is sent to the parties.
2. WCB File Number:
Enter the jurisdiction claim number assigned by the State of Maine to identify this claim.
Employee
3. Employee Last Name:
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.
4. First Name:
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.
5. M.I.:
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.
6. Social Security Number:
Enter the employee's ID # as it was entered in box 31 of the Employers First Report of Occupational Injury or Disease, WCB-1.
7. Street/P.O. Box Mailing Address:
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.
8. City:
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.
9. State:
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.
10. Zip:
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.
11. Home Phone Number:
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.
| 12. | Date of Injury: | ___/ | ___/ | ____ |
| MM | DD | YYYY |
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.
13. Specific Injury or Illness:
Enter the specific injury or illness as it was entered in box 48 of the Employers First Report of Occupational Injury or Disease, WCB-1.
14. Body Part(s) Affected:
Enter body part(s) affected as it was entered in box 49 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Employer
15. Insurer File Number:
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.
16. Employer Name:
Enter the employer name as it was entered in box 10 of the Employers First Report of Occupational Injury or Disease, WCB-1.
17. Employer Mailing Address and Phone Number:
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.
18. Insurer/TPA Name:
Enter the legal name of the insurance company, self-insured or guarantee fund assuming the employers financial responsibility for this claim, and the legal name of the entity adjusting the claim as it was entered in box 19 of the Employers First Report of Occupational Injury or Disease, WCB-1.
19. Insurer/TPA Mailing Address:
Enter the claim administrator mailing address as it was entered in boxes 22-25 of the Employers First Report of Occupational Injury or Disease, WCB-1.
Notice to Employee
20. Your Employer/Insurer is required to file this Workers Compensation form upon payment of a lost time work-related injury. Payment is made for the following reason:
A. Your Claim is Accepted (payment with prejudice).
Check box A if the employer/insurer is accepting the claim.
B. This is a Voluntary Payment Pending Investigation (payment w/out prejudice).
Check box B if the employer/insurer plans to investigate the claim.
C. This is a Mandatory Payment Because a Notice of Controversy Was Not
Timely Filed Pursuant to Rule 1.1. Period Covered by Mandatory Payment:
| From (Date) | ___/ | ___/ | ____ | Through (Date) | ___/ | ___/ | ____ | Amount Paid | $____________ |
| MM | DD | YYYY | MM | DD | YYYY |
Check box C if payment is required because a Notice of Controversy was not timely filed pursuant to Rule 1.1. The employee must be paid total incapacity benefits, with credit for earnings and other statutory offsets, from the date of incapacity through the later of the filing date of a Notice of Controversy or the payment date of any accrued benefits.
21. Type of Payment:
A. Weekly Compensation (§212(1), 213(1) or former §54, 54-A, 54-B, 55, 55-A, 55-B)
B. Specific Loss ______Weeks Amount Paid $____________ (§212(3))
C. Permanent Impairment Amount Paid $____________ (Pre 1993 claims only)
D. Other (Explain) ___________
Check the box that describes the reason for the payment.
If Specific Loss is checked, enter the number of weeks payable and the total amount to be paid through the end of the specific loss period.
If Permanent Impairment is checked, enter the amount paid for permanent impairment.
If Other is checked, enter a brief description of the type of payment, e.g. Salary Continuation, Board decision, occupational deafness (§612), etc.
22. A. Is There Any Indication That the Injury is Permanent? Yes No
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.
| 23. | Date of Incapacity: | ___/ | ___/ | ____ |
| MM | DD | YYYY |
Initial MOP: Enter the first day qualifying as a day of disability as it was entered in box 43 of the Employers First Report of Occupational Injury or Disease, WCB-1.
(Occupational disease claims: enter the date of injury reported in box 12.)
Subsequent MOP: Enter the first day qualifying as a day of disability in the current period of disability being paid.
Specific loss claims (initial or subsequent MOP): enter the date of the specific loss.
| Date Employer Notified: | ___/ | ___/ | ____ | |
| MM | DD | YYYY | ||
Enter the date that the employer was notified or had knowledge of the above date of disability/incapacity.
| 24. | Date Check Mailed: | ___/ | ___/ | ____ |
| MM | DD | YYYY |
Enter the date payment was first mailed to the employee for the current incapacity. For cases involving salary continuation, enter the date the payroll check is mailed or delivered or the salary is deposited.
25. Average Weekly Wage:
Enter the employees average weekly wage pursuant to §102(4). If estimated, please indicate. Do not enter the escalated average weekly wage (Pre 1993 claims only).
26. Current Weekly Compensation Rate:
Total Partial $
Check the appropriate box to indicate whether payment is for total or partial incapacity.
Also, enter the dollar amount of the current compensation rate or applicable maximum. (Rates are based on the law in effect at the time of the injury.) Enter Varying Rate in place of the dollar amount for varying rates. For cases involving salary continuation, enter the compensation rate that would otherwise be paid or the applicable maximum.
27. Does Employee Work for Another Employer? Yes No
If Yes, Give Name: ___________________________________
If the employee was employed by more than one employer at the time of the injury, check Yes, otherwise, check No If Yes is checked, enter the name of each other employer.
| 28. | First Day of Compensability After Waiting Period is Met: | ___/ | ___/ | ____ |
| MM | DD | YYYY |
Complete this box if (1) the current incapacity is subject to the seven-day waiting period provided by §204, or (2) this is the initial MOP for a firefighter claim. Otherwise, do not complete this box.
For non-firefighter claims, enter the first day of incapacity after the seven-day wait has been met. For firefighter claims, enter the date of incapacity reported in box 23.
In the case of total incapacity, the seven-day waiting period is met when the employee is incapacitated for seven calendar days (regardless of salary continuation). In the case of partial incapacity, the seven-day waiting period is met when (1) an employee loses wages because of the injury which cumulatively equal or exceed the employees pre-injury AWW, or (2) an employee loses wages because of the injury that would otherwise require the insurer to pay one week of benefits. For cases involving salary continuation, this calculation should be made as if the employee has lost the wage that is being continued during the time he or she is absent from work or when the employee misses time from work that equals the hours worked in a regular work week. See Appendix H for more information.
29.
Is This an Apportionment Claim?
Yes
No If Yes, answer the following:
Other Date(s) of Injury Involved: ____________________________________________________
Other Carrier(s) Involved: __________________________________________________________
Who is the Lead Carrier? _________________________________________________________
Explain the Terms of the Apportionment: ______________________________________________
If this claim has been apportioned with another work-related injury, check Yes, otherwise, check No. If Yes is checked, answer all questions asked about the apportionment.
30. Comments
Use this area to enter any additional information, explanations or clarifications. For cases involving salary continuation, enter the salary amount that is being paid and any additional partial workers compensation benefits due under §213, as applicable.
Preparer Information
31. Claim Handler Name (Type or Print)::
Enter the claim handlers name.
E-Mail Address:
Enter the claim handlers email address.
32. Telephone Number:
Enter the claim handlers telephone number, including area code.
Toll Free Number:
Enter the claim handlers toll free telephone number if one is available.
| 33. | Date Sent to WCB: | ___/ | ___/ | ____ |
| MM | DD | YYYY |
Enter the date (month, day, year) this form is sent (mail, fax, email) to the Workers Compensation Board. If the form being sent is a revision of a previous form, maintain the original "Date Sent to WCB" date and enter the revision date in box 1.