PETITION FOR REVIEW OF INCAPACITY 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: DATE OF BIRTH: SOCIAL SECURITY NUMBER: (only last four digits required) BOARD FILE NUMBER: XXX-XXNAME: STREET/P.O. BOX: CITY, STATE, ZIP: INSURER NAME: STREET/P.O. BOX: CITY, STATE, ZIP: EMPLOYER NOTICE A party is not required to file a written response to this petition under 39-A M.R.S.A. §307(3). Upon notice of a claim for incapacity or death benefits, however, the employer/insurer must comply with the provisions of 90 MAR 351 Ch.1. §1 or the employee must be paid total benefits, with credit for earnings and other statutory offsets, from the date the claim is made in accordance with 39-A M.R.S.A. §205(2) and in compliance with 39-A M.R.S.A. §204. 1. On , EMPLOYER NAME MONTH DAY YEAR EMPLOYEE NAME sustained a work-related . incapacity. injury while working for 2. Compensation of $ 3. The employee's incapacity has per week is being paid for . PARTIAL / TOTAL (INSERT ONE) INCREASED / DECREASED / ENDED (INSERT ONE) THEREFORE, the petitioner asks the board to review the amount of compensation paid pursuant to Title 39 or 39-A. __________________________________________________________ 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 named in 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: (888) 801-9087 or TTY Maine Relay 711. WCB-120 (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com