Petition For Award Of Compensation - Occupational Disease Law
Petition For Award Of Compensation - Occupational Disease Law Form. This is a Maine form and can be use in Workers Compensation.
Tags: Petition For Award Of Compensation - Occupational Disease Law, WCB-160, Maine Workers Compensation,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. PETITION FOR AWARD OF COMPENSATION - OCCUPATIONAL DISEASE LAW : JUDICIAL SUBPOENA Plaintiff(s) STATE OF MAINE -againstWORKERS COMPENSATION :BOARD 27 STATE HOUSE STATION : AUGUSTA, MAINE 04333-0027 EMPLOYEE EMPLOYER ) NAME: : ) STREET/P.O. BOX: STREET/P.O. BOX: Defendant(s) : ...................................................... ) CITY, STATE, ZIP: CITY, STATE, ZIP: TELEPHONE NUMBER: _______________________________________ ) EMPLOYEE SOCIAL SECURITY NUMBER: ________________________ ) THE PEOPLE OF THE STATE OF NEW YORK NAME: BOARD FILE NUMBER: ________________________________________ ) (IF KNOWN) TO ) STREET/P.O. BOX: NAME: INSURANCE COMPANY CITY,STATE, ZIP: 1. On , MONTH GREETINGS: DAY YEAR EMPLOYEE NAME developed a work-related disease while working for . EMPLOYER NAME 2. Date of last WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before exposure: _______________________________________________. MONTH DAY YEAR , the Honorable at the Court located at County of 3. Date of incapacity: _______________________________________________. DAY in room , on theMONTH day of , YEAR , at 20 o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 4. Date employment ceased: _____________________________. MONTH DAY YEAR 5. Describe how the exposure occurred: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a 6. Describeof your failure to comply. result the occupational disease: 7. List the bodyWitness, Honorable part(s) affected: Court in County, , one of the Justices of the day of , 20 WHEREFORE, the employee asks the Board to award the payment of compensation pursuant to 39-A M.R.S.A. ____________________________________________ SIGNATURE OF EMPLOYEE DATED(Attorney must sign above and type name below) : __________________________________________________________________ MONTH DAY YEAR FILING INSTRUCTIONS 1. NAME OF EMPLOYEE'S ATTORNEY OR ADVOCATE (IF ANY) Mail original petition to the Workers Compensation Board at the Attorney(s) for above address by regular mail. 2. Mail one (1) copy by certified mail, return receipt requested to the STREET/P.O. BOX insurance company. 3. Mail one (1) copy by certified mail, return receipt requested to the employer. CITY, STATE, ZIP 4. Keep one (1) copy for yourself and keep the green certified mail Office and P.O. Address 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 DEPARTMENT S ADA COORDINATOR. WCB-160 (06/98) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com