Petition For Award Of Compensation
Petition For Award Of Compensation Form. This is a Maine form and can be use in Workers Compensation.
Tags: Petition For Award Of Compensation, WCB-140, Maine Workers Compensation,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. PETITION FOR AWARD OF COMPENSATION : JUDICIAL SUBPOENA Plaintiff(s) STATE OF MAINE -againstWORKERS COMPENSATION :BOARD 27 STATE HOUSE STATION : AUGUSTA, MAINE 04333-0027 PETITIONER ) NAME: NAME: : RESPONDENT Defendant(s) ) . . . . . . . . .: STREET/P.O. .BOX: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STREET/P. O. BOX: .... ... ) CITY, STATE, ZIP: TELEPHONE NUMBER: _______________________________________ ) THE PEOPLE OF THE STATE OF NEW YORK EMPLOYEE SOCIAL SECURITY NUMBER: ________________________ ) NAME: BOARDTO NUMBER: ________________________________________ ) FILE (IF KNOWN) ) STREET/P.O. BOX: CITY, STATE, ZIP: ) CITY, STATE, ZIP: GREETINGS: 1. On MONTH RESPONDENT , DAY YEAR EMPLOYEE NAME WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before . , the Honorable at the Court EMPLOYER NAME located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed 2. Describe how the injury occurred: ___________________________________________________________________ or adjourned date, to testify and give evidence as a witness in this action on the part of the experienced a work-related injury while working for 3. List body part(s) injured: __________________________________________________________________________ ______________________________________________________________________________________________to Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 4. The employee ____________________ lose time from work. DID, DID NOT (SELECT ONE) Witness, Honorable one of M.R.S.A. (check all WHEREFORE, the petitioner asks the Board to order the following benefits pursuant ,to 39-A the Justices of the that apply): Court in County, day of , 20 _____ Weekly lost time benefits _____ Protection of the Act _____ Specific loss benefits ____________________________________________ SIGNATURE OF PETITIONER EMPLOYEE FILING INSTRUCTIONS (Attorney must sign above and type name below) DATED: __________________________________________________________________ MONTH DAY YEAR NAME OF PETITIONER'S Attorney(s) for 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 the insurance company. 3. Mail one (1) copy by certified mail, return receipt requested to the CITY, STATE, employer. Office and P.O. Address ZIP 4. Keep one (1) copy for yourself and keep the green certified mail cards when returned to you by the U.S. Post Office. THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES OR ACTIVITIES. THIS MATERIAL CAN BE MADE AVAILABLE IN ALTERNATE FORMATS BY CONTACTING YOUR Telephone No.: DEPARTMENT S ADA COORDINATOR. WCB-140 (06/98) Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com