Fill and Sign the Employee Petition for Review of Incapacity and Mainegov Form

EMPLOYEE PETITION FOR REVIEW OF INCAPACITY AND REQUEST FOR PROVISIONAL ORDER STATE OF MAINE W ORKERS ' COMPENSATION BOARD 27 STATE HOUSE STATION AUGUSTA, MAINE 04333 -0027 EMPLOYEE EMPLOYER NAME: STREET/P.O. BOX: CITY, STATE, ZIP: TELEPHONE N UMBER: NAME: STREET/P.O. BOX: CITY, STATE, ZIP: DATE OF BIRTH: INSURER SOCIAL SECURITY NUMBER: XXX -XX - (only last four digits required) BOARD FILE NUMBER: NAME: STREET/P.O. BOX: CITY, STATE, ZIP: 1. On , sustained a work -related MONTH DAY YEAR EMPLOYEE NAME injury while working for . EMPLOYER NAME 2. Compensation of $ per week is being paid for incapacity. PARTIAL / TOTAL (INSERT ONE) 3. Compensation benefits were as of . REDU CED / DISCONTINUED (INSERT ONE) MONTH DAY YEAR 4. The employer should reinstate the employee’s weekly compensation benefits for the following reasons: (Attach recent medical reports and/or other documents to support this p etition.) T HEREFORE, the employee asks that the b oard issue a provisional order reinstating compensation benefits pursuant to 39 -A M.R.S. A. §205. __________________________________________________________ SIG NATURE OF PETITIONER FILING INSTRUCTIONS 1. Mail original petition to the W orkers ’ Compensation Board at the above address by regular mail. 2. Mail one (1) copy by certified mail, return receipt requested to each other party named in the petition. 3. Keep one (1) copy for yourself and keep the green certified mail cards when returned to you by the U.S. Post Office. DATED: MONTH DAY YEAR NAME OF EMPLOYEE'S ATTORNEY OR ADVOCATE (IF ANY) STREET/P.O. BOX CITY, STATE, ZIP TELEPHONE NUMBER The S tate 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 W or kers’ Compensation Board. Telephone: (888) 801-9087 or TTY Maine Relay 711. W CB -12 1 (eff. 1/1/13 )