PETITION FOR EXTENSION OF BENEFITS DUE TO EXTREME FINANCIAL HARDSHIP PURSUANT TO 39-A M.R.S.A. §213(1) 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 NOTICE Within 15 days of the date that the employee's petition is filed, the employee must respond to the questions contained in Appendix I of 90 MAR 351 Ch. 2, and send those responses to the employer. 1. Compensation of $ per week was being paid for partial incapacity. . 2. Compensation benefits were discontinued as of MONTH DAY YEAR 3. This case involves extreme financial hardship due to the employee's inability to return to gainful employment. THEREFORE, the employee requests an expedited proceeding and asks that the board extend benefits pursuant to 39-A M.R.S.A. §213(1). __________________________________________________________ SIGNATURE OF PETITIONER DATED: MONTH DAY YEAR FILING INSTRUCTIONS 1. 2. 3. Mail original petition to the Workers' Compensation Board at the above address by regular mail. Mail one (1) copy by certified mail, return receipt requested to each other party listed on 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. NAME OF PETITIONER'S ATTORNEY OR ADVOCATE (IF ANY) STREET/P.O. BOX CITY, STATE, ZIP 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: 1-888-801-9087 or TTY Maine Relay 711. WCB-213 (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com