MOTION FOR AWARD OF FEES AND DISBURSEMENTS STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 1. INSURER FILE NUMBER: 2. EMPLOYER NAME: 6. SOCIAL SECURITY NUMBER (last 4 digits): 7. WCB FILE NUMBER: 9. FIRST NAME: 10. M.I.: XXX-XX8. EMPLOYEE LAST NAME: 3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: 11. ADDRESS-NUMBER AND STREET: 4. INSURER NAME: 12. CITY: 13. STATE: 14. ZIP: 15. HOME PHONE: 5. INSURER MAILING ADDRESS: 16. DATE OF INJURY: 17. DESCRIPTION OF INJURY: 18. REASON FOR MOTION: (CHECK ALL THAT APPLY) AWARD OF ATTORNEY'S FEES AND/OR DISBURSEMENTS (ATTACH ITEMIZED STATEMENT INDICATING DATES COVERED BY THIS MOTION) AWARD OF WITNESS FEES OTHER (EXPLAIN) ___________________________________________________________________________________________ 19. AMOUNTS REQUESTED: ATTORNEY'S FEES: DISBURSEMENTS: WITNESS FEES: OTHER: TOTAL: $ ______________________ $ ______________________ $ ______________________ $ ______________________ $ ______________________ STREET ADDRESS NAME 20. PAYMENT TO BE MADE TO: CITY, STATE, ZIP CERTIFICATION AND SIGNATURE (Motion Must Be Signed) 21. I,___________________________________________________, hereby certify that I have caused a copy of this motion to be served upon counsel for the employer, (or, if there was no legal representation, directly upon the opposing party) ___________________________________________ (Name) at __________________________________________________________, on _____________________________________ by United States (Address) (Date) mail, postage prepaid. Signature ___________________________________________________ Date ___________________________________ ORDER 22. THE EMPLOYER/INSURER IS ORDERED TO PAY THE PAYEE NAMED ABOVE THE SUM OF $_______________________________ AS FOLLOWS: $ _____________________________________ FOR ATTORNEY'S FEES $ _____________________________________ FOR DISBURSEMENTS $ _____________________________________ FOR WITNESS FEES $ _____________________________________ OTHER PAYMENTS ______________________________________________________ Administrative Law Judge _____________________ Date 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-25 (eff. 1/1/13, rev. 10/15/15) American LegalNet, Inc. www.FormsWorkFlow.com