Petition For Review Of Incapacity
Petition For Review Of Incapacity Form. This is a Maine form and can be use in Workers Compensation.
Tags: Petition For Review Of Incapacity, WCB-120, Maine Workers Compensation,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. PETITION FOR REVIEW OF INCAPACITY : JUDICIAL SUBPOENA Plaintiff(s) STATE OF MAINE -againstWORKERS COMPENSATION :BOARD 27 STATE HOUSE STATION : AUGUSTA, MAINE 04333-0027 : RESPONDENT PETITIONER Defendant(s) ) : ...................................................... NAME: ___________________________________________ STREET/.P.O.BOX: CITY, STATE, ZIP: THE PEOPLE OF THE STATE OF NEW YORK TELEPHONE NUMBER: _________________________________ TO EMPLOYEE SOCIAL SECURITY NUMBER: _________________ BOARD FILE NUMBER: (IF KNOWN) GREETINGS: ) ) ) ) ) ) ) NAME: STREET/P.O.BOX: ______________________________________ CITY, STATE, ZIP: RESPONDENT NAME: ________________________________________________ STREET/P.O. BOX : CITY, STATE, ZIP: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 1. On Honorable , ______________________________________________ , the at the Court MONTH DAY YEAR EMPLOYEE NAME located at County of in room , on the day working for , 20 , at o'clock in the noon, and at any recessed experienced a work-related injury while of . EMPLOYER NAME or adjourned date, to testify and give evidence as a witness in this action on the part of the 2. Compensation of $ per week is being paid for __________ incapacity. PARTIAL, TOTAL (SELECT ONE) 3. The employee's incapacity has . 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 aINCREASED, DECREASED, ENDED $50 and all damages sustained as a maximum penalty of (SELECT ONE) result of your failure to comply. WHEREFORE, the petitioner asks the Board to review the amount of compensation ,paid pursuant to 39-A M.R.S.A. Witness, Honorable one of the Justices of the Court in County, day of _____________________________________________ SIGNATURE OF PETITIONER , 20 DATED: ___________________________________________________ MONTH (Attorney must sign above and DAY name below) type YEAR EMPLOYEE FILING INSTRUCTIONS 1. 2. 3. 4. 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 the insurance company. Mail one (1) copy by certified mail, return receipt requested to the employer. Keep one (1) copy for yourself and keep the green certified mail cards when returned to you by the U.S. Post Office. Attorney(s) for _________________________ NAME OF PETITIONER'S ATTORNEY OR ADVOCATE (IF ANY) STREET/P.O. BOX Office and P.O. Address CITY, STATE, ZIP THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS Telephone No.: PROGRAMS, SERVICES OR ACTIVITIES. THIS MATERIAL CAN BE MADE AVAILABLE IN ALTERNATE FORMATS BY CONTACTING YOUR DEPARTMENT S ADA COORDINATOR. WCB-120 (6/98) Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com