Claims Information & Forms

Supervisor's Report of Injury
*Required for all lost time injuries
Supervisor Report.pdf
Adobe Acrobat document [104.9 KB]
Employee Report of Injury
Employee Report of Injury.pdf
Adobe Acrobat document [201.3 KB]
Medical Release Form
Medical Authorization.pdf
Adobe Acrobat document [87.1 KB]
Wage Statement
Wage Statement.pdf
Adobe Acrobat document [59.7 KB]
Schedule of Dependents
Schedule of Dependents.pdf
Adobe Acrobat document [8.6 KB]
Medical Authorization
Medical Authorization.pdf
Adobe Acrobat document [87.1 KB]
CMS Legal Documentation
CMS Form V2.pdf
Adobe Acrobat document [282.8 KB]
Mileage Reimbursement Form
Mileage Reimbursement Form.pdf
Adobe Acrobat document [20.4 KB]

Maintaining a safe workplace in accordance with all laws is your responsibility. Our safety information and recommendations relate to underwriting concerns and do not constitute an assumption by us of your obligations to provide a safe workplace. We make no representation or warranty that our activities or information will place you in compliance with the law or that your premises or operations are safe. We exercise no control over your premises or operations and have no responsibility or authority to implement loss control recommendations. You are not entitled to rely upon any loss control activities provided by us, and you may not delegate any of your legal responsibilities to us.

2011 Payroll Audits

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Questions?

Contact us anytime:

 

Pam Demers

Sue Morang

Gary Thebarge

Brian Parke

 

MMTA Workers' Comp. Trust

PO Box 5198

Augusta, ME 04332-5198

Phone: (207)623-1807

Fax: (207)622-6804