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DISCONTINUANCE OR MODIFICATION OF COMPENSATION, WCB-4
Reporting Requirements
The employer or insurer (which can sometimes be one and the same) files this form for such reasons as the discontinuance or modification of compensation pursuant to 39-A M.R.S.A. §205(9)(A), a Board decision, cost-of-living adjustments, Social Security offsets, and unemployment compensation offsets. NOTE: This form is not used for discontinuances or reductions under 39-A M.R.S.A. §205(9)(B).
When the employee's benefits are discontinued or modified in accordance with a decree, a Discontinuance or Modification of Compensation must be sent (mail, fax, etc.) to the Board (Central Office).
When the employee's benefits are discontinued or modified in accordance with an agreement between the parties, a Discontinuance or Modification of Compensation must be sent (mail, fax, etc.) to the Board within 14 days from the date of the agreement. Three mail days are provided for receipt by the Board. Evidence of timely mailing is a rebuttable presumption.
When the employee's benefits are discontinued, reduced or modified for any other reason (voluntary increase, §205(9)(A) discontinuance or reduction, cost‑of‑living adjustment, Social Security offset, unemployment offset, etc.), a Discontinuance or Modification of Compensation must be sent (mail, fax, etc.) to the Board.
Distribution
The Discontinuance or Modification of Compensation 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 Violation
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 DISCONTINUANCE
OR MODIFICATION OF COMPENSATION, WCB-4
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 Discontinuance or Modification of Compensation is filed, enter it here. The Board will record it for reference.
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.
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 speedup processing this form. Electronic filers (EDI) users must complete this box.
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 of 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 the employee’s mailing address.
City
Enter the city of the employee’s mailing address.
State
Enter the state of the employee’s mailing address.
Zip
Enter the zip code of the employee’s mailing address.
Home Phone Number
Enter the employee’s home telephone number, including area code.
Date of Injury
Enter the date of the employee's 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 or illness.
Discontinuance
Reason for Discontinuance
Returned to Work for Same Employer §205(9)(A)
Board Decision
Increased Earnings §205(9)(A)
Other (Explain) ____________
Check the box that describes the reason for discontinuing compensation. If "Other" is checked, provide a brief explanation for the discontinuance.
Period of Incapacity
From (Date):
Enter the date (month, day, year) incapacity began. This date should be the same as box 23 (date of incapacity) of the Memorandum of Payment, WCB-3, for the current incapacity period.
To (Return Date): Enter the date (month, day, year) this incapacity ended. This is the date the employee returned to work. NOTE: Enter only one period of incapacity in box 19 per form.
Weekly Compensation Rate
Enter the weekly compensation rate used for this period of incapacity. If more than one rate was used, enter the last rate used.
Amount Paid
Enter the total amount (in dollars and cents) of weekly compensation paid for the period of incapacity reported in box 19.
Date of Final Payment
Enter the date (month, day, year) of the last weekly compensation payment for this period of incapacity was mailed to the employee.
Modification
Reason for Modification
Returned to Work for Same Employer §205(9)(A)
Increased Earnings §205(9)(A)
Decreased Earnings
Cost of Living Adjustments
Average Weekly Wage Established
Other (Explain) ___________
Check the box that describes the reason for modification. If “Other” is checked, provide a brief explanation for the modification.
Old Compensation Rate
Enter the compensation rate (in dollars and cents, unless varying rates are paid) prior to the change. If varying rates were paid, enter the word "varying."
New Compensation Rate
Enter the new compensation rate (in dollars and cents, unless varying rates are paid). If varying rates will be paid, enter the word "varying."
Effective Date of Modification
Enter the date (month, day, year) the rate change took effect.
Comments
Use this area to enter any additional information, explanation, or clarification.
Preparer Information
Preparer Name and Title
Type or print the preparer’s name.
Telephone Number
Enter the preparer's telephone number, including area code.
Date Mailed
Enter the date (month, day, year) this form is sent (mail, fax, etc.) to the Workers' Compensation Board.
