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Employer and Employee Instructions
CONSENT BETWEEN EMPLOYER AND EMPLOYEE, WCB-4A
Reporting Requirements
The employer or insurer (which can sometimes be one and the same) must file a Consent Between Employer and Employee with the Board (Central Office) when compensation is initiated, reduced, modified or discontinued pursuant to an agreement of the parties outside the litigation process.
Distribution
The Consent Between Employer and Employee 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 CONSENT BETWEEN
EMPLOYER AND EMPLOYEE, WCB-4A
Identifying Information
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 Certificate of Discontinuance or Reduction of Compensation, 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 insurer, self‑insured, or third‑party administrator if there is one.
Insurer Mailing Address
Enter the insurer, self‑insurer, 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.
Terms of Consent
Terms of Consent
Enter the details/terms of the agreement between the parties.
18A. Date of Incapacity
Use this box when compensation is being initiated by agreement of the parties. Enter the
date of the first day of incapacity that will be compensated.
18B. Average Weekly Wage
Enter the Average Weekly Wage. This amount should be the same as the average weekly
wage listed on the Wage Statement. Do not enter the escalated Average Weekly Wage.
18C. Current Weekly Compensation Rate:
18D. Does Employee Work For Another Employer?
Yes
No
If the employee was employed by more than one employer at the time of the injury, check “Yes.” Otherwise, check “No.”
If Yes, Give Name(s)
If the employee was employed by more than one employer at the time of the injury, enter the name of the other employer(s). NOTE: The employer for whom the employee worked at the time of the injury is required to file the Wage Statement(s) from the employee’s other employer(s) (§205.8).
18E. New Compensation Rate
Enter the new compensation rate (in dollars and cents, unless varying rates are paid), as
agreed upon by the parties. If varying rates will be paid, enter the word “varying.”
18F. Effective Date of Reduction
Enter the effective date of the reduction, as agreed upon by the parties.
18G. Effective Date of Discontinuance
Enter the effective date of the discontinuance, as agreed upon by the parties.
18H. Amount Paid
Use this box when compensation is being discontinued by agreement of the parties.
Enter the total amount of indemnity to be paid for the incapacity period being
discontinued by the agreement of the parties.
Notice To Employee
This box should be initialed by the employee to ensure that he/she has read the notice.
Consent
This area must be signed and dated by both parties, or their representatives, before it may be accepted by the Workers’ Compensation Board.
Preparer Information
Preparer Name and Title
Type or print the claim handler’s name.
E-Mail Address
Enter the claim handler’s e-mail address (optional).
Telephone Number
Enter the claim handler’s telephone number, including area code.
Toll Free Number
Enter the claim handler’s toll free telephone number if one is available.
Date Sent to WCB: ___/___/____ MM DD YYYY
Enter the date (month, day, year) this form is sent (mail, fax, etc.) to the Workers’ Compensation Board.
