Petition For Reinstatement
Petition For Reinstatement Form. This is a Maine form and can be use in Workers Compensation.
Tags: Petition For Reinstatement, WCB-171, Maine Workers Compensation,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. PETITION FOR REINSTATEMENT : JUDICIAL SUBPOENA Plaintiff(s) STATE OF MAINE -againstWORKERS COMPENSATION :BOARD 27 STATE HOUSE STATION : AUGUSTA, MAINE 04333-0027 EMPLOYEE ) NAME: NAME: EMPLOYER : 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: ________________________________________ ) STREET/P.O. BOX: FILE (IF KNOWN) ) CITY, STATE, ZIP: CITY, STATE, ZIP: 1. On INSURANCE COMPANY , GREETINGS: MONTH DAY Y EAR EMPLOYEE NAME experienced a work-related injury while working for . WE COMMAND YOU, that all business and excuses beingEMPLOYER NAMEyou and each of you attend before laid aside, , the Honorable at the Court 2. List the body part(s) injured : located at County of in room , on the day of , 20 , at 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 3. On ______________________________, I contacted the employer and requested the following (check all that apply): MONTH DAY YEAR _____ Reinstatement to my former position _____ Placement in an available position for which I was qualified and physically able to perform 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 4. On _________________________________________, the employer denied this request. MONTH DAY result of your failure to comply. YEAR WHEREFORE, the employee asks the Board to order the following benefits pursuant to 39-A M.R.S.A. (check all that Witness, Honorable , one of the Justices of the apply): _____ Payment of weeklyday of during the,period of denial or until I accept other employment and benefits Court in County, 20 earn a wage in excess of my average weekly wage. _____ Reinstatement to my former position or any other available position for which I am qualified and physically able to perform. (Attorney must sign above and type name below) _____ Other (specify): ____________________________________________________ SIGNATURE OF EMPLOYEE DATED: ___________________________________________________ MONTH DAY YEAR Attorney(s) for FILING INSTRUCTIONS NAME OF EMPLOYEE'S ATTORNEY OR ADVOCATE (IF ANY) 1. Mail original petition to the Workers Compensation Board at the STREET/P.O. BOX above address by regular mail. 2. Mail one (1) copy by certified mail, return receipt requested to the insurance company. Office and P.O. Address ZIP CITY, STATE, 3. Mail one (1) copy by certified mail, return receipt requested to the employer. 4. Keep one (1) copy for yourself and keep the green certified mail cards when returned to you by the U.S. Post Office. Telephone No.: 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 Facsimile No.: DEPARTMENT S ADA COORDINATOR. E-Mail Address: WCB-171 (06/98) Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com