Code of Maine Rules
90 - INDEPENDENT AGENCIES
351 - WORKERS' COMPENSATION BOARD
Chapter 8 - PROCEDURES FOR PAYMENT
Section 351-8-18

1. The Consent Between Employer and Employee (WCB-4A) may be used when the parties have agreed to a voluntary payment of a retroactive closed-end period of incapacity, or a modification, reduction or discontinuance in ongoing weekly incapacity benefits. The Consent Between Employer and Employee (WCB-4A) may be used when the parties agree to discontinue or reduce benefits during the 21-day period following the filing of a Certificate of Discontinuance or Reduction of Compensation (WCB-8). The Consent Between Employer and Employee (WCB-4A) cannot be used to reduce or discontinue benefits on a date that is subsequent to the date the parties sign the WCB-4A.

2. The WCB-4A shall be signed by the employee or a representative of the employee, and a representative of the insurer.

3. The parties may agree to the pre-injury average weekly wage or may agree to pay benefits based upon a provisional wage and reserve the issue of the pre-injury average weekly wage for later determination by the Board. In either event, the form shall also indicate whether the employee is receiving 100% of the benefits at issue for the designated period. If the employee is receiving less than 100% of the benefits at issue for the designated period, the form shall indicate the percentage of benefits that the employee is receiving.

4. The employer or insurance carrier shall make compensation payments within 10 calendar days after the WCB-4A is signed by the parties.

5. Signing the WCB-4A does not by itself create a compensation payment scheme.

6. The WCB-4A shall be distributed as follows:

7. Upon request by any of the parties, the Consent Between Employer and Employee, WCB-4A, shall be reviewed within 14 calendar days by an agent at the Board's regional offices in order to answer any relevant questions prior to the employer and employee signing this form.

8. The Consent Between Employer and Employee, WCB-4A, shall not be used when an ongoing order, award of compensation, or a compensation payment scheme is entered under §205(9)(B)(2).

9. The Payments Division will review the filed Consent Between Employer and Employee, WCB-4A, in order to verify that the agreed upon benefits were correctly determined.

10. The Deputy Director of Benefits Administration will refer abuses of the Consent Between Employer and Employee, WCB-4A, to the Workers' Compensation Abuse Investigation Unit.