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{"sheet":"WCB-2","index":0,"n_rows":43,"n_cols":15,"rows_kept":43,"cut":false,"hidden":false,"merged":[[37,3,37,4],[37,5,37,6],[38,0,38,14],[39,0,39,6],[39,7,39,11],[39,12,39,14],[35,3,35,4],[35,5,35,6],[35,11,35,13],[36,3,36,4],[36,5,36,6],[36,9,36,13],[37,9,37,13],[35,9,35,10],[33,3,33,4],[33,5,33,6],[33,9,33,10],[33,11,33,13],[34,3,34,4],[34,5,34,6],[34,9,34,10],[34,11,34,13],[31,3,31,4],[31,5,31,6],[31,9,31,10],[31,11,31,13],[32,3,32,4],[32,5,32,6],[32,9,32,10],[32,11,32,13],[29,3,29,4],[29,5,29,6],[29,9,29,10],[29,11,29,13],[30,3,30,4],[30,5,30,6],[30,9,30,10],[30,11,30,13],[27,3,27,4],[27,5,27,6],[27,9,27,10],[27,11,27,13],[28,3,28,4],[28,5,28,6],[28,9,28,10],[28,11,28,13],[25,3,25,4],[25,5,25,6],[25,9,25,10],[25,11,25,13],[26,3,26,4],[26,5,26,6],[26,9,26,10],[26,11,26,13],[23,3,23,4],[23,5,23,6],[23,9,23,10],[23,11,23,13],[24,3,24,4],[24,5,24,6],[24,9,24,10],[24,11,24,13],[21,3,21,4],[21,5,21,6],[21,9,21,10],[21,11,21,13],[22,3,22,4],[22,5,22,6],[22,9,22,10],[22,11,22,13],[10,0,10,14],[19,9,19,10],[5,0,5,14],[12,0,12,3],[18,0,18,14],[20,3,20,4],[20,5,20,6],[20,9,20,10],[20,11,20,13],[12,4,12,14],[19,11,19,13],[8,4,9,4],[13,0,13,14],[14,0,14,14],[15,0,15,1],[17,0,17,14],[40,0,40,5],[40,7,40,11],[40,12,40,14],[0,0,0,14],[2,0,2,14],[1,0,1,14],[9,0,9,3],[8,5,9,10],[8,11,9,14],[4,0,4,1],[3,2,4,13],[3,14,4,14],[3,0,3,1],[6,11,6,14],[7,11,7,12],[7,13,7,14],[11,4,11,9],[11,10,11,14],[6,0,6,3],[6,4,6,9],[7,0,7,3],[7,4,7,9],[8,0,8,3],[11,0,11,3]]}
["STATE OF MAINE"]
["WORKERS' COMPENSATION BOARD"]
["27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027"]
["1. REVISION DATE: \n                                           ",null,"WAGE STATEMENT",null,null,null,null,null,null,null,null,null,null,null,"2. WCB FILE NUMBER: (REQUIRED) \n      \n"]
["                                   MM/DD/YYYY"]
["EMPLOYEE"]
["3. EMPLOYEE LAST NAME: \n",null,null,null,"4. FIRST NAME: \n",null,null,null,null,null,"5. MI:\n","6. SOCIAL SECURITY NUMBER (last 4 digits):\n    XXX-XX-"]
["7. STREET/P.O. BOX MAILING ADDRESS:  \n",null,null,null,"8. CITY: \n",null,null,null,null,null,"9. STATE: \n","10. ZIP: \n",null,"11. HOME PHONE NUMBER: \n"]
["12. DATE OF INJURY:\n                                     ",null,null,null,null,"13. SPECIFIC INJURY OF ILLNESS: \n\n",null,null,null,null,null,"14. BODY PART (S) AFFECTED: \n"]
["                                      MM/DD/YYYY"]
["EMPLOYER/INSURER"]
["15. INSURER FILE NUMBER:  \n",null,null,null,"16. EMPLOYER NAME: \n",null,null,null,null,null,"17. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: \n"]
["18. INSURER NAME: \n",null,null,null,"19. INSURER MAILING ADDRESS AND PHONE NUMBER: \n"]
["20. DOES EMPLOYEE WORK CONCURRENTLY?             YES                                  NO                                    IF YES, A WAGE STATEMENT MUST BE SUBMITTED FOR EACH EMPLOYER\n\nNAME(S) OF EMPLOYERS: ________________________________ ; __________________________________ ; _____________________________________"]
["\n21. DOES EMPLOYEE RECEIVE FRINGE BENEFITS THAT MAY STOP WHILE ON WORKERS’ COMPENSATION?                                      YES                                  NO                                       \n\nIF YES: THE AVERAGE WEEKLY WAGE MUST BE RECALCULATED IF/WHEN FRINGE BENEFITS CEASE (SEE RULE 1.5(2))"]
["22. METHOD OF CALCULATION:",null,"102(4)(A) – SALARIED",null,null,null,null,"102(4)(C) – SEASONAL WORKER"]
[null,null,"102(4)(B) – VARYING WAGES  ",null,null,null,null,"102(4)(D) – OTHER*   "]
["*NOTE: IF WAGES WERE CALCULATED USING SECTION 102(4)(D), YOU MUST SUBMIT COMPARABLE WAGES WITH THIS FILING AND PROVIDE A DETAILED EXPLANTION OF THE CALCULATION IN THE COMMENTS BOX."]
["23. LIST GROSS EARNINGS FOR EACH WEEK"]
["WK","WEEK ENDING","GROSS EARNINGS","WK",null,"WEEK ENDING",null,"GROSS EARNINGS",null,"WK",null,"WEEK ENDING",null,null,"GROSS EARNINGS"]
[1,{"$f":"SUM(B22-7)","v":-357},null,19,null,{"$f":"SUM(F22-7)","v":-231},null,null,null,37,null,{"$f":"SUM(L22-7)","v":-105}]
[2,-350,null,20,null,-224,null,null,null,38,null,-98]
[3,-343,null,21,null,-217,null,null,null,39,null,-91]
[4,-336,null,22,null,-210,null,null,null,40,null,-84]
[5,-329,null,23,null,-203,null,null,null,41,null,-77]
[6,-322,null,24,null,-196,null,null,null,42,null,-70]
[7,-315,null,25,null,-189,null,null,null,43,null,-63]
[8,-308,null,26,null,-182,null,null,null,44,null,-56]
[9,-301,null,27,null,-175,null,null,null,45,null,-49]
[10,-294,null,28,null,-168,null,null,null,46,null,-42]
[11,-287,null,29,null,-161,null,null,null,47,null,-35]
[12,-280,null,30,null,-154,null,null,null,48,null,-28]
[13,-273,null,31,null,-147,null,null,null,49,null,-21]
[14,-266,null,32,null,-140,null,null,null,50,null,-14]
[15,-259,null,33,null,-133,null,null,null,51,null,-7]
[16,-252,null,34,null,-126,null,null,null,"WK OF \nINJURY"]
[17,-245,null,35,null,-119,null,null,null,"24. TOTAL EARNINGS",null,null,null,null,{"$f":"SUM(C21:C38,H21:H38,O21:O36)","v":0}]
[18,{"$f":"SUM(F21-7)","v":-238},null,36,null,{"$f":"SUM(L21-7)","v":-112},null,null,null," 25. GROSS AVERAGE \n        WEEKLY WAGE"]
["26. COMMENTS: \n"]
["27. TYPE OR PRINT PREPARER NAME (REQUIRED): \n       ",null,null,null,null,null,null,"28. TELEPHONE NUMBER (REQUIRED): \n",null,null,null,null,"29. DATE MAILED TO WCB: \n"]
["   E-MAIL ADDRESS (REQUIRED): ",null,null,null,null,null,null,"   TOLL-FREE NUMBER: ",null,null,null,null,"                                MM / DD / YYYY"]
["The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance"]
["with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board. Telephone: 1-888-801-9087 or TTY Maine Relay 711. WCB-2 (eff. 4-1-2025)"]

{"sheet":"Instructions","index":1,"n_rows":2,"n_cols":1,"rows_kept":2,"cut":false,"hidden":false,"merged":[]}
["To enter data in boxes with existing text: In the formula bar, after the text, use the down arrow on your keyboard to go down one line within the box."]
["To autofill dates in Box 23: Enter the week of injury (Column L, Row 32)."]