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WCB 190A Petition

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PETITION FOR AWARD OF COMPENSATION

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: XXX-XX-

(only last four digits required)

BOARD FILE NUMBER:

EMPLOYER

NAME:

STREET/P.O. BOX:

CITY, STATE, ZIP:

INSURER

NAME:

STREET/P.O. BOX:

CITY, STATE, ZIP:

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 sustained a work-related

injury while working for

2. The employee gave notice of incapacity from work for his/her work-related injury on/about

3. The injury occurred

and the employee injured his/her

4. The employee lose time from work.

THEREFORE, the employee asks the board to order benefits pursuant to Title 39 or 39-A.

SIGNATURE OF PETITIONER

DATED:

FILING INSTRUCTIONS

  1. Mail original petition to the Workers' 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.

NAME OF EMPLOYEE'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-140 (eff. 1/1/13)

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What the WCB 190A Petition Is and when it applies

The WCB 190A Petition is a workers' compensation board petition form used to request Board action on an existing claim, to reopen benefits, or to seek a hearing or modification of an order. It collects claimant and employer identification, claim or docket number, a concise statement of facts and legal grounds, a clear description of the relief requested, and space for supporting exhibits. The form is structured so the Board can identify jurisdiction, scope of dispute, and the parties to be served, enabling administrative review or scheduling of a hearing.

Why the WCB 190A Petition matters for claim resolution

Filing a WCB 190A Petition starts formal Board review when a claimant or employer seeks adjudication, correction, or reopening of a workers' compensation matter. It provides the Board with a clear statement of relief sought and attaches the facts and records needed to set a hearing or issue a revised determination.

Why the WCB 190A Petition matters for claim resolution

Who typically completes and files a WCB 190A Petition

The form is prepared and filed by parties with an interest in a workers' compensation claim: injured workers, employer representatives, insurers, or attorneys acting on their behalf.

  • Claimant filing for reopening or modification of benefits
  • Employers or insurers disputing benefit payment or seeking clarification
  • Attorneys or authorized representatives submitting evidence and legal argument

Filing rules, required attachments, and service procedures vary by state or Board; check the Board's procedural instructions before submission.

Step-by-step: completing a WCB 190A Petition

Follow these four core steps to prepare a complete petition and reduce the chance of return or rejection.

  • 01
    Gather records: Collect prior Board orders, medical reports, and wage records to support your grounds.
  • 02
    Complete form: Fill every required field, use MM/DD/YYYY dates, and print legibly if submitting paper.
  • 03
    Attach exhibits: Label and index supporting documents; include a cover list referencing each exhibit.
  • 04
    File and serve: Submit to the Board per local rules and serve all parties using the Board-approved method.

Typical routing and processing flow for a WCB 190A Petition

A completed petition is routed through administrative intake, assigned to a judge or analyst, and either scheduled for hearing or adjudicated on the written record.

  • Intake: Clerical review for completeness and correct claim number.
  • Assignment: Document assigned to a hearing officer or adjudicator.
  • Disposition: Board schedules a hearing or issues an order based on submissions.
  • Service: Final order served to parties with appeal instructions.

How to configure an e-filing workflow for a WCB 190A Petition

Set up fields and signer steps to mirror Board requirements so every submission includes required metadata and exhibits.

Field Configuration
Claim Number Field Mandatory, single-line, validation for numeric/alphanumeric values
Date Fields MM/DD/YYYY format, calendar widget to avoid errors
Exhibit Upload Allow multiple PDF uploads, file name limit and index field
Signer Authentication Email + SMS code or stronger KBA when required

Digital submission essentials and integration considerations

Ensure your e-filing platform supports the Board's accepted file formats, signer authentication, and service records before submitting electronically.

  • File Formats: PDF, DOCX accepted by many Boards
  • Integrations: Connect with case management systems and cloud storage
  • Authentication: Email + SMS or higher-strength methods

Maintain a copy of the completed petition and proof of service. Confirm the platform captures an audit trail with timestamps, IP addresses, and completed signer actions for administrative records.

Six essential parts of a professional WCB 190A Petition

Include the elements below to present a clear, Board-ready petition that supports efficient review and reduces requests for additional information.

Case Identification

Claimant name, employer, insurer, and Board-assigned claim or docket number for precise tracking.

Statement of Facts

Concise chronology of relevant events and dates showing why corrective action or reopening is warranted.

Legal Basis

Cite the rule or statutory provision relied on and the specific grounds for relief or modification.

Relief Requested

Specify the exact remedy sought, such as back benefits, medical authorization, or correction of an award.

Exhibits Index

Number and describe attachments (medical records, wage statements, prior orders) in an exhibit list.

Service Information

Identify how each party was served and include certificate of service or proof of mailing.

Security and compliance considerations for electronic WCB 190A filings

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
Access Controls: Role-based permissions and SSO support
Audit Trail: Comprehensive timestamps, IP, and action logs
HIPAA BAA: BAA available when PHI included
Certifications: SOC 2 Type II; ISO 27001 available
Authentication: Email, SMS, KBA, or advanced methods

Common preparation pitfalls to avoid

  • Incomplete claim identifiers cause intake delays and misrouting to incorrect dockets, requiring re-filing.
  • Mismatched party names between prior orders and the petition often lead to service or verification problems.
  • Missing or unindexed exhibits force the Board to request additional documentation and extend processing time.
  • Incorrect date formats or ambiguous injury dates can complicate jurisdictional determinations and timeliness assessments.

Consequences of an incorrect or incomplete petition

Return for Correction: May occur
Filing Rejection: Possible
Delay in Benefits: Likely
Adverse Rulings: Risk if facts unsupported
Service Defects: Can void proceedings
Increased Legal Costs: Common

Timing considerations and statutory responsiveness

Timing and deadlines vary by jurisdiction. File promptly and confirm any state-specific or Board-prescribed filing windows to preserve rights.

Initial Filing Window:

Varies by state — file promptly after new evidence

Response Period:

Board or opposing parties typically have set days to respond; see local rules

Hearing Scheduling:

Scheduling time varies; high-volume Boards may set hearings weeks to months later

Appeal Deadlines:

Strict statutory appeal periods apply — verify with Board rules

Record Retention:

Keep original and certified copies per retention policy

Key milestones from filing to final Board action

A typical petition lifecycle follows distinct milestones from preparation through final order and possible appeal.

01

Prepare Petition

Assemble facts, exhibits, and service list before filing.

02

File With Board

Submit via Board portal or clerk per local rules.

03

Serve Parties

Provide proof of service to the Board and other parties.

04

Hearing / Decision

Board schedules hearing or issues adjudication on the record.

How WCB 190A differs from similar petition or review forms

This comparison highlights a WCB 190A petition versus a generic administrative petition used in other tribunals; check the Board rules for exact scope.

Criteria WCB 190A Generic Admin Petition
Primary Use workers' comp relief broad administrative relief
eSignature Allowed often varies
Notarization sometimes varies
Filing Agency workers' compensation board agency or court

eSignature vendor pricing and capabilities relevant to petition filing

Compare baseline pricing and common capabilities for eSignature platforms used to prepare and submit petitions. signNow is listed first per vendor comparison conventions.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day trial Unknown Unknown Unknown Unknown
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Practical examples of when a WCB 190A Petition is used

These two scenarios illustrate common uses—reopening a closed claim and correcting an administrative error on a prior order.

Reopen for Medical Evidence

A claimant obtains new medical imaging showing a later-discovered condition

  • Evidence confirms worsening symptoms
  • The petition attaches the new report, explains why it was not previously available, and requests reopening to consider additional medical benefits and treatment authorization.

Clerical Correction

An employer identifies a pay-rate error on the award calculation

  • The employer provides payroll records
  • The petition requests correction of wage factors, supplies supporting paystubs, and asks the Board to issue an amended benefits computation.

Frequently asked questions about the WCB 190A Petition

Answers to common filing and process questions to help avoid delays and ensure the Board can process your petition efficiently.


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