Report an Injury for Maine

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*Internet Explorer is not recommended for First Report of Injury submissions*

Fields marked with an asterisk (*) are required—you cannot submit the form unless these fields are completed.

1. Lost time - one or more days*

Yes No

2. Was employee paid for 1/2 day or more on day of injury?

Yes No

3. Lost earnings but no lost time*

Yes No

4. Medical only

Yes No

5. Fatality date of death (mm/dd/yyyy)

6. Occupational disease

Yes No

7. If yes, date of last exposure (mm/dd/yyyy)

8. Date of diagnosis as occupationally related (mm/dd/yyyy)

9. Correct prior report

Yes No

10. If yes, date of correction (mm/dd/yyyy)

11. Date correction sent to WCB (mm/dd/yyyy)

12. State Employer UIAN*

13. FEIN*

14. Employer Name *

15. Street/P.O. Box Mailing Address*

16. City*

17. State*

18. Zip*

19. Phone Number*

20. Primary business performed by employer where injury occurred

21. Employer location (if different from Mail Address)

22. Did injury or exposure occur on employer's premises?

Yes No

23. If no, then please give name and physical address of the employer where the employee was injured or exposed.

24. Employer contact person*

25. Insurance Company Named on Workers’ Compensation Policy

A.I.M. Mutual Insurance Co. Associated Employers Insurance Co. New Hampshire Employers Insurance Co.

26. Policy Number*

27. Insurer File Number

28. Street/P.O. Box Mailing Address

29. City

30. State

31. Zip

32. Telephone Number

33. Employee's Last Name*

34. Employee's First Name*

35. Employee Telephone*

36. Phone Type*

Home Cell Work

37. Employee Personal Email Address

38. Social Security Number*

39. Sex*

Male Female Unknown

40. Street/P.O. Box Mailing Address*

41. City*

42. State*

43. ZIP*

44. Date of Birth (mm/dd/yyyy)*

45. Occupation/Job Title

46. Date of Hire*

47. Employment Status*

48. Weekly wage a time of injury*

49. Does employee work for another employer?

Yes No

50. Marital status*

Single Married Separated Unknown

51. Date of Injury or Illness*

52. Date employer notified*

53. Date of incapacity*

54. Time employee began work

55. Date employer notified insurer*

56. Time of injury

57. Has the employee returned to work?*

Yes No

58. If yes, what date?

59. Specific injury or illness

60. Body part(s) affected

61. All equipment, materials, or chemicals employee was using when the event occurred

62. Specify activity the employee was engaged in when the event occurred*

63. Was activity part of normal job duties?

Yes No

64. How injury or illness occurred*

65. Hospitalized overnight as inpatient

Yes No

66. Was the employee treated in the emergency room?

Yes No

67. Health care provider name

68. Health care provider mailing address

69. Health care provider phone number

70. Preparer name and title*

71. Preparer phone number

72. Preparer email address*

73. Comments

74. Attachment field (medical records)
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