REQUEST FOR EXPEDITED PROCEEDING STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 1. INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER (last 4 digits): XXX-XX- 7. WCB FILE NUMBER: 2. EMPLOYER NAM E: 8. EMPLOYEE LAST NAME: 9. FIRST NAME: 10. M.I.: 3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: 11. ADDRESS - NUMBER AND STREET: 4. INSURER NAME: 12. CITY: 13. STATE: 14. ZIP: 15. HOME PHONE: 5. INSURER MAILING ADDRESS: 16. DATE OF INJURY: 17. DESCRIPTION OF INJURY: PURSUANT TO 90 MAR 351 CH. 1. 2479, THIS REQUEST FOR EXPEDITED PROCEEDING (WCB-250) MUST BE ATTACHED TO THE FRONT OF THE APPROPRIATE PETITION AND SUPPORTING DOCUMENTS. 18.I REQUEST AN EXPEDITED PROCEEDING (CHOOSE ONE OF THE FOLLOWING): BASED ON A DISCONTINUANCE OR REDUCTION OF PAYMENTS PURSUANT TO 39-A M.R.S.A. 247205(9)(E). BASED ON MATTERS INVOLVING MEDICAL CARE OR THE RIGHT TO BENEFITS FOR TOTAL INCAPACITY PURSUANT TO 39-A M.R.S.A. 247315. EXPLANATION: SIGNATURE OF REQUESTING PARTY DATE NAME, ADDRESS, AND TELEPHONE OF ATTORNEY (IF ANY): REPRESENTING (CHECK ONE): EMPLOYEEEMPLOYER ASSISTANCE IS AVAILABLE AT THE MAINE WORK ERS222 COMPENSATION BOARD222S REGIONAL OFFICES AUGUSTA 442 CIVIC CTR DR, STE 225 156 STATE HOUSE STATION AUGUSTA, ME 04333-0156 (207)287-2308 1 - 800 - 400 - 6854 BANGOR 106 HOGAN RD BANGOR, ME 04401-5638 (207)941-4550 1 - 800 - 400 - 6856 CARIBOU ONE VAUGHN PL 43 HATCH DR, STE 110 CARIBOU, ME 04736 (207)498-6428 1 - 800 - 400 - 6855 LEWISTON 36 MOLLISON WAY LEWISTON, ME 04240-7777 (207)753-7700 1 - 800 - 400 - 6857 PORTLAND 1037 FOREST AVE, STE 11 PORTLAND, ME 04103 (207)822-0840 1 - 800 - 400 - 6858 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 Workers222 Compensation Board. Telephone: 1-888-801-9087 or Maine Relay 711. WCB-250 (eff. 1/1/13, rev. 1/28/19) American LegalNet, Inc. www.FormsWorkFlow.com