PETITION TO DETERMINE ENTITLEMENT TO REHABILITATION SERVICES PURSUANT TO 39-A M.R.S.A. §217(2) 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: INSURER SOCIAL SECURITY NUMBER: (only last four digits required) BOARD FILE NUMBER: XXX-XXNAME: STREET/P.O. BOX: CITY, STATE, ZIP: NAME: STREET/P.O. BOX: CITY, STATE, ZIP: EMPLOYER 1. On MONTH DAY YEAR , EMPLOYEE NAME sustained a work-related . EMPLOYER NAME injury while working for 2. The employee is ABLE / UNABLE (INSERT ONE) to perform work for which he/she has previous training or experience. 3. The proposed plan IS / IS NOT (INSERT ONE) likely to return the employee to suitable employment at a reasonable cost. THEREFORE, the petitioner asks the board to determine the employee's entitlement to rehabilitation services pursuant to 39-A M.R.S.A. §217(2). __________________________________________________________ SIGNATURE OF PETITIONER DATED: MONTH DAY YEAR FILING INSTRUCTIONS NAME OF PETITIONER'S ATTORNEY OR ADVOCATE (IF ANY) 1. Mail original petition to the Workers' Compensation Board at the above address by regular mail. STREET/P.O. BOX 2. 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. CITY, STATE, ZIP 3. 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. WCB-321 (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com