Get Wage Statement - Maine.gov - Maine

Filling out the Wage Statement is an important step in the workers' compensation process in Maine. This guide will help you navigate the form with clarity and confidence, ensuring you provide all necessary information accurately and efficiently.

Follow the steps to complete the Wage Statement effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your document management system.
2. Start by entering the insurer file number in the designated field. This number identifies your insurance provider's records.
3. Fill in the employer’s name, ensuring the spelling is correct. This helps to verify employment details.
4. Provide the employer mailing address and phone number. This is essential for any further communication regarding the form.
5. Next, enter the insurer's name and mailing address. Accurate information is crucial for processing any claims.
6. Input the last four digits of the employee's social security number for identity verification.
7. Complete the employee’s last name, first name, and middle initial to clearly identify the worker involved.
8. Fill out the home phone number where the employee can be reached, followed by their address, city, state, and zip code.
9. State the date of injury and provide a brief description of the injury, as this information is vital for claims processing.
10. Answer whether the employee works concurrently for another employer. If yes, list the additional employer's name(s). Note: a separate wage statement must be submitted for each employer.
11. Indicate if the employee receives fringe benefits that may stop while on workers' compensation and remember that recalculation of the average weekly wage is necessary if benefits cease.
12. Document the gross earnings for each week listed in the form. Ensure that all fields are filled out correctly for the designated weeks.
13. Provide any additional comments if necessary, which may assist in clarifying any information on the form.
14. Type or print the preparer’s name, e-mail address, and telephone number. This allows for follow-up communication if needed.
15. Lastly, indicate the date the form was mailed and ensure all information is complete before proceeding to save, download, print, or share the form as required.

Complete your Wage Statement online today to ensure accurate processing of your workers' compensation claims.