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Home > Insurance Programs > Workers’ Compensation > How to File A Claim Checklist

How to File A Claim Checklist

* We recommend the First Report of Injury be submitted within 24-48 hours of employer’s knowledge or notice of an injury or claim to avoid penalties assessed by the Workers Compensation Board.

1. Employer’s First Report of Occupational Injury or Disease (WCB-1) (FIRST REPORT)

2. Supervisor’s Incident Report (ER-REPORT.doc)

3. Employee’s Incident Report (EE-REPORT.doc)

4. Limited Certificate…Medical Authorization (WCB-220) (MED-AUTH.pdf)

5. CMS (Centers for Medicare Services) Legal Documentation (CMS – INFO.pdf)

** Above forms must be emailed to Betti-Jeanne Bullock at bjbullock@msmaweb.com or faxed to (207) 620-7090.

Other forms that may be required/requested:

• Fringe Benefit Worksheet (WCB-2B) (FRINGE.pdf)

• Wage Statement (WCB-2) (WAGE.pdf)

• Mileage Reimbursement Form (msma-mileage-claims.doc)