Form Wcb 282 PDF Details

In the landscape of workers' compensation in Maine, the WCB 282 form plays a crucial role in maintaining the integrity and fairness of the claims process. This form, officially known as the Complaint for Audit, serves as a formal channel through which complaints against insurers, self-administered employers, or third-party administrators can be submitted to the Workers' Compensation Board Office of Monitoring, Audit, and Enforcement. The form requires detailed information, including the name of the insurer or administrator, claim handler details, and specifics about the claim such as the Workers’ Compensation Board File number, name and address of the employee, and the nature of the injury. Furthermore, it outlines the nature of the complaint, asking for supporting documentation and highlighting the complainant's request for the Board to investigate potential violations of the Maine Revised Statutes Annotated (M.R.S.A.) Section 359. These violations could involve questionable claims-handling techniques, repeated unreasonably contested claims, willful violations of the Act, or instances of fraud or intentional misrepresentation. The ultimate goal is for the Board to assess any applicable penalties and ensure compliance with workers' compensation laws, safeguarding the interests of employees across the state.

QuestionAnswer
Form NameForm Wcb 282
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesWCB 282 chartis 101 riverfront blvd ste 100 bradenton fl 34205 form

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STATE OF MAINE

WORKERS' COMPENSATION BOARD

OFFICE OF MONITORING, AUDIT AND ENFORCEMENT

27 STATE HOUSE STATION

AUGUSTA, MAINE 04333-0027

PAUL R. LEPAGE

GOVERNOR

COMPLAINT FOR AUDIT

PAUL H. SIGHINOLFI, ESQ.

EXECUTIVE DIRECTOR/CHAIR

Insurer, Self-Administered Employer or Third-Party Adjusting Company (TPA)

Name of Insurer, Self-Administered Employer or TPA: ___________________________________________________________

Claim Handler Name: _____________________________________________________________________________________

Street Address: __________________________________________________________________________________________

City/State/Zip Code: ______________________________________________________________________________________

Telephone: (_____)_______________________________________________________________________________________

Claim(s) Involved

Workers’ Compensation Board File # (if available): _____________________________________________________________

Name of Employee: ______________________________________________________________________________________

Street Address: __________________________________________________________________________________________

City/State/Zip Code: ______________________________________________________________________________________

Telephone: (_____)_______________________________________________________________________________________

Social Security Number (only last four digits required): __________________________________________________________

Date of Injury: ___________________________________________________________________________________________

Nature of Complaint (attach supporting documentation):

_____________________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

The Complainant asks the Board to conduct an investigation to determine if the insurer, self-administered employer or third-party administrator has violated 39-A M.R.S.A. Section 359 by engaging in a pattern of questionable claims-handling techniques or repeated unreasonably contested claims and/or has violated Section 360(2) by committing a willful violation of the Act or committing fraud or intentional misrepresentation. The Complainant asks that the Board assess all applicable penalties.

Party Filing Complaint

Name: _________________________________________________________________________________________________

Street Address: ___________________________________________________________________________________________

City/State/Zip Code:_______________________________________________________________________________________

Telephone: (_____)________________________________________________________________________________________

______________________________________ ____________________________________________

Signature of Complainant

 

Date of Complaint

TEL: 207-287-7067

TTY: Maine Relay 711

FAX: 207-287-7198

WCB-282 (eff. 1/1/13)

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