C.M.R. 90, 351, ch. 12, app 351-12-II
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.
C.M.R. 90, 351, ch. 12, app 351-12-II