Form Wcb 282 PDF Details

Workers' compensation is a system in place to provide benefits to employees who are injured or become ill as a result of their job. In order to receive workers' compensation benefits, you must have a work-related injury or illness and file a claim with your employer. The Workers' Compensation Board (WCB) administers the workers' compensation system in Alberta. If you are injured or become ill as a result of your job, here's what you need to know about filing a claim with the WCB. Injured on the Job? Here's What You Need to Know About Filing a Claim With the WCB | WorkAlberta https://www.workalberta.ca/injured-on-the-job-heres-what-you-need-to-know-about-filing-a-claim-with -the - wcb /#!

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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