Petition For Restoration
Petition For Restoration Form. This is a Maine form and can be use in Workers Compensation.
Tags: Petition For Restoration, WCB-170, Maine Workers Compensation,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. PETITION FOR RESTORATION : JUDICIAL SUBPOENA Plaintiff(s) STATE OF MAINE -againstWORKERS COMPENSATION :BOARD 27 STATE HOUSE STATION : AUGUSTA, MAINE 04333-0027 : EMPLOYEE NAME: EMPLOYER Defendant(s) ) NAME: : ...................................................... ) STREET/P.O. BOX: ) CITY, STATE, ZIP: CITY, STATE, ZIP: TELEPHONE NUMBER: _______________________________________ ) THE PEOPLE OF THE STATE OF NEW YORK EMPLOYEE SOCIAL SECURITY NUMBER: ________________________ ) NAME: TO BOARD FILE NUMBER: ________________________________________ ) STREET/P.O. BOX: (IF KNOWN) ) CITY, STATE, ZIP: STREET/P.O. BOX: GREETINGS: 1. On MONTH INSURANCE COMPANY , DAY YEAR EMPLOYEE NAME WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before experienced a work-related injury while working for . , 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 3. List the body part(s) injured: _______________________________________________________________________. 4. Compensation of $________________________ per week was paid for ____________________________________. PARTIAL/TOTAL INCAPACITY (SELECT ONE) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on benefitsbehalf this subpoena was issued for a maximum of __________________________________. a 5. Compensation whose were________________________________ as penalty of $50 and all damages sustained as REDUCED/DISCONTINUED/ (SELECT ONE) MONTH DAY YEAR result of your failure to comply. 6. As of _________________________________, a new period of _____________________________________ exists. Witness,DAY HonorableYEAR Court in County, , one of the Justices of the MONTH PARTIAL/TOTAL INCAPACITY (SELECT ONE) day of , 20 WHEREFORE, the employee asks the Board to order the restoration of the following benefits pursuant to 39-A M.R.S.A. (check all that apply): _____ Weekly lost time benefits _____ Specific loss benefits (Attorney must sign above and type name below) _____ Other (please specify) ___________________________________________ DATED: __________________________________________________________________ SIGNATURE OF EMPLOYEE FILING INSTRUCTIONS MONTH DAY YEAR Attorney(s) for ATTORNEY OR ADVOCATE (IF ANY) NAME OF EMPLOYEE'S 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 Office and P.O. Address ZIP CITY, STATE, 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. 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. Facsimile No.: WCB-170 (06/98) E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com