EMPLOYEE PETITION FOR REVIEW OF INCAPACITY AND REQUEST FOR PROVISIONAL ORDER STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027 EMPLOYEE NAME: STREET/P.O. BOX: CITY, STATE, ZIP: TELEPHONE NUMBER: DATE OF BIRTH: SOCIAL SECURITY NUMBER: (only last four digits required) BOARD FILE NUMBER: XXX-XXNAME: STREET/P.O. BOX: CITY, STATE, ZIP: INSURER NAME: STREET/P.O. BOX: CITY, STATE, ZIP: EMPLOYER 1. On MONTH DAY YEAR , EMPLOYER NAME EMPLOYEE NAME sustained a work-related . incapacity. . injury while working for 2. Compensation of $ 3. Compensation benefits were per week is being paid for as of PARTIAL / TOTAL (INSERT ONE) REDUCED / DISCONTINUED (INSERT ONE) MONTH DAY YEAR 4. The employer should reinstate the employee's weekly compensation benefits for the following reasons: (Attach recent medical reports and/or other documents to support this petition.) THEREFORE, the employee asks that the board issue a provisional order reinstating compensation benefits pursuant to 39-A M.R.S.A. §205. __________________________________________________________ SIGNATURE OF PETITIONER DATED: MONTH DAY YEAR FILING INSTRUCTIONS 1. 2. 3. Mail original petition to the Workers' Compensation Board at the above address by regular mail. Mail one (1) copy by certified mail, return receipt requested to each other party named in the petition. Keep one (1) copy for yourself and keep the green certified mail cards when returned to you by the U.S. Post Office. NAME OF EMPLOYEE'S ATTORNEY OR ADVOCATE (IF ANY) STREET/P.O. BOX CITY, STATE, ZIP TELEPHONE NUMBER 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: (888) 801-9087 or TTY Maine Relay 711. American LegalNet, Inc. WCB-121 (eff. 1/1/13) www.FormsWorkFlow.com