Petition To Determine Extent Of Permanent Impairment
Petition To Determine Extent Of Permanent Impairment Form. This is a Maine form and can be use in Workers Compensation.
Tags: Petition To Determine Extent Of Permanent Impairment, WCB-180, Maine Workers Compensation,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. PETITION TO DETERMINE EXTENT OF PERMANENT IMPAIRMENT : JUDICIAL SUBPOENA Plaintiff(s) STATE OF MAINE -againstWORKERS COMPENSATION :BOARD 27 STATE HOUSE STATION : AUGUSTA, MAINE 04333-0027 : RESPONDENT PETITIONER NAME: Defendant(s) ) NAME: : ...................................................... ) STREET/P.O. BOX: ) CITY, STATE, ZIP: CITY, STATE, ZIP: TELEPHONE NUMBER: _______________________________________ ) THE PEOPLE OF THE STATE OF NEW YORK NAME: EMPLOYEE SOCIAL SECURITY NUMBER: _______________________ ) STREET/P.O. BOX: TO BOARD FILE NUMBER: ________________________________________ ) (IF KNOWN) ) CITY, STATE, ZIP: STREET/P.O. BOX: 1. On GREETINGS: MONTH RESPONDENT , DAY Y EAR EMPLOYEE NAME experiencedWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before a work-related injury while working for . EMPLOYER NAME , the Honorable at the Court Countyhow the injury occurred : located at of 2. Describe 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. The injury resulted in a permanent impairment to (list body part(s) affected): 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 result of your failure to comply. WHEREFORE, the petitioner asks the Board to determine the extent of permanent impairment. Witness, Honorable Court in County, , one of the Justices of the day of ____________________________________________________ SIGNATURE OF PETITIONER , 20 DATED: ___________________________________________________ MONTH DAY 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 copy for yourself and keep the green certified mail cards when returned to you by the Post Office. NAME OF PETITIONER'S ATTORNEY OR name below) (Attorney must sign above and type ADVOCATE (IF ANY) STREET/P.O. BOX Attorney(s) for CITY, STATE, ZIP THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS Office and P.O. Address PROGRAMS, SERVICES OR ACTIVITIES. THIS MATERIAL CAN BE MADE AVAILABLE IN ALTERNATE FORMATS BY CONTACTING YOUR DEPARTMENT S ADA COORDINATOR. WCB-180 (06/98) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com