The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon Board. Telephone: (888) 801-9087 or TTY Maine Relay 711. WCB-410 (eff. 2/1/17) COMPLAINT FOR PENALTIES 39-A 247205(4) STATE OF MAINE WORKERS' COMPENSATION BOARD ABUSE INVESTIGATION UNIT 27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027 PETITIONER RESPONDENT - INSURER [CHECK ONE]: HEALTH CARE PROVIDER EMPLOYEE NAME : STREET/P.O. BOX : NAME : STREET/P.O. BOX: CITY, STATE, ZIP: CITY, STATE, ZIP: TELEPHONE NU MBER: BOARD FILE NUMBER (if known): NOTICE A party is not required to file a written response to this petition under 39-A M.R.S.A. 247307(3). 1.On , sustained a MONTH DAY YEAR EMPLOYEE NAME work-related injury while working for . EMPLOYER NAME 2.[CHECK ONE]: On , the employee sent the employer/insurer copies of bills paid for MONTH DAY YEAR by the employee for medical or health care services related to the injury. - OR - On , the health care provider sent the employer/insurer copies of MONTH DAY YEAR bills for medical or health care services related to the work-related injury. 3.The bills were sent by certified mail. [YOU MUST ATTACH PROOF OF SERVICE BY CERTIFIED MAIL.]4.There is no ongoing dispute regarding the claim and the insurer/employer has failed to pay the medical bills submittedto it within thirty (30) days after receiving notice, by certified mail, of nonpayment of the bills.WHEREFORE, I request such penalties as I may be entitled pursuant to Title 39-A 247205(4). SIGNATURE OF PETITIONER FILING INSTRUCTIONS 1. Mail original petition to the Workers Compensation Board at the above address by regular mail. 2. Mail one (1) copy by certified mail, return receipt requested , to each other party named in the petition. 3 . Keep one (1) copy for yourself and keep the green certified mail cards when returned to you by the U.S. Post Office. D ATED: MONTH DAY YEAR NAME OF S ATTORNEY OR ADVOCATE (IF ANY) STREET/P.O. BOX CITY, STATE, ZIP TELEPHONE NUMBER American LegalNet, Inc. www.FormsWorkFlow.com