Application For Wage Credit Rehabilitation Fund {WCB-322}

APPLICATION FOR WAGE CREDIT EMPLOYMENT REHABILITATION FUND STATE OF MAINE WORKERS' COMPENSATION BOARD OFFICE OF MEDICAL/REHABILITATION SERVICES 27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027 HIRING EMPLOYER NAME: STREET/P.O. BOX: CITY, STATE, ZIP: TELEPHONE NUMBER: NAME: STREET/P.O. BOX: CITY, STATE, ZIP: TELEPHONE NUMBER: EMPLOYEE NOTICE TO EMPLOYER Pursuant to 39-A M.R.S.A. §355(6)(A), the employer must file an application for a wage credit by providing the board, within two (2) weeks after the close of the first 90 days of employment of the employee, with a statement of the total direct wages, earnings or salary the employer paid to the employee for the first 90 days of employment along with such verification as may be required by rule of the board. Within two (2) weeks after the close of the first 180 days of employment, the subsequent employer must provide to the board a supplemental report of the direct wages, earnings and salary for the second 90-day period, along with the required verification. COMPLETE THE FOLLOWING INFORMATION: A. B1. Employee date of hire: Total direct wages, earnings or salary the employer paid to the employee for the first 90 days of employment (attach verification): Total direct wages, earnings or salary the employer paid to the employee for the second 90 days of employment (attach verification): Comments: B2. C. THEREFORE, the employer asks the board for a wage credit pursuant to 39-A M.R.S.A. §355(6). __________________________________________________________ SIGNATURE OF APPLICANT DATED: MONTH DAY YEAR FILING INSTRUCTIONS 1. Mail original application to the Workers' Compensation Board at the above address by regular mail. Keep one (1) copy for yourself. FOR BOARD USE ONLY Claim Administrator: 2. WCB File Number(s): Calculation of Wage Credit: Adjuster Name: The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers' Compensation Board. Telephone: (888) 801-9087 or TTY Maine Relay 711. American LegalNet, Inc. WCB-322 (eff. 1/1/13) www.FormsWorkFlow.com