Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 12 - FORMAL HEARINGS › Appendix 351-12-II - Exchange of Information Form

Current through 2024-29, July 17, 2024
Information the Employee Must Supply to the Employer
(Please respond to all questions that are relevant to the
				  pending proceeding.)
Write on separate sheets of paper the following information
				  in your own words. Make your answers as complete as you can and send them to
				  the employer/insurance carrier.
1. Your full name, age, and level of
				  education/training.
2. Describe the injury: the nature of the injury, how and
				  when it happened, when you realized that the injury resulted from your work,
				  who at work you told about the injury, and when you told that person.
3. Have you worked since the injury? If so, when, where, and
				  how much did you earn? Have you received unemployment benefits since the
				  injury? If so, state the period of time you received benefits, state whether
				  the benefits are ongoing, and state how much is or was the weekly amount
				  received.
4. What medical treatment have you received as a result of
				  your work injury? Include the names and addresses of doctors, hospitals, and
				  other health care providers you have seen because of this injury.
5. Have you ever injured the same body part before?
Do you have any pre-existing medical conditions related to
				  that body part? If so, describe any medical treatment you have received for
				  those injuries or conditions and include the names of doctors, hospitals, and
				  other health care providers that treated you for those injuries or
				  conditions.
6. Please indicate with a yes or no whether your employer
				  pays for all or part of any fringe benefits such as health, life, disability,
				  dental insurance, or contributions to a 401(k) or pension plan.
7. Please state whether you are asking to be reinstated to
				  the job you were working in when you were injured or to another job for the
				  same employer.
8. List all the jobs you have had over the past 10 years,
				  when you had each job, and what your duties were in each job.
9. List all of your witnesses, other than yourself and your
				  medical providers, and give a short summary of their testimony.
10. Have you suffered any other injuries since you were
				  injured at work? If you have, describe when and how each injury happened and
				  provide the names and addresses of doctors, hospitals, and any other health
				  care providers that you saw because of those injuries.
11. Please provide a description of your current daily
				  activities.
12. Please tell whether you have engaged in any sports,
				  recreational, or home maintenance activities after your date of injury.
13. Are there activities you can no longer do as a result of
				  your injury? If so, describe those activities.
14. Please state whether you have received Old Age Social
				  Security benefits since the date of your injury.
EXCHANGE OF INFORMATION FORM
Information Employer/Insurance Carrier Must Supply to
				  the Employee
(Please respond to all questions that are relevant to the
				  pending proceeding.)
1. If the employee has requested reinstatement, please list
				  all positions available from the date of that request through the present that
				  are within the employee's limitations and within a reasonable distance from the
				  employee's residence. State whether you have offered the employee his or her
				  old position back or whether you have offered reinstatement to another
				  position. If so, describe the position.
2. Supply all relevant wage information including a wage
				  statement and complete fringe benefits information. State what the employee's
				  average weekly wage was at the time of the injury and supply wage statements
				  for comparable employees if the petitioning employee was employed by you for
				  less than six months.
3. Except as provided in section
				  11, subsections
				  3 and
				  4 of this chapter, state whether the
				  employer has any evidence that the employee's reports of limitations or other
				  history given to any person in this case are inaccurate and state the basis for
				  that contention. Provide relevant documentary and written information.
4. Supply a copy of the employee's personnel file consistent
				  with
Harding v. Walmart Stores, Inc
., 2001 ME 13, 765 A.2d
				  73.
5. State the legal name of your business, the number of
				  employees it employs, and the nature of your operation.
6. List your witnesses and give a summary of their
				  testimony.
7. Give the name(s) and the position(s) of the person(s)
				  supplying this information.