Fill and Sign the Petition for Award of Compensation Fatal Form

PETITION FOR AWARD OF COMPENSATION - FATAL STATE OF MAINE W ORKERS ' COMPENSATION BOARD 27 STATE HOUSE STATION AUGUSTA, MAINE 04333 -0027 PETITIONER EMPLOYER NAME: STREET/P.O. BOX: CITY, STATE, ZIP: TELEPHONE NUMBER: NAME: STREET/P.O. B OX: CITY, STATE, ZIP: RELATIONSHIP TO DECEASED: INSURER EMPLOYEE NAME: DATE OF BIRTH: EMPLOYEE SOCIAL SECURITY NUMBER: XXX -XX - (only last four digits required) BOARD FILE NUMBE R: NAME: STREET/P.O. BOX: CITY, STATE, ZIP: N OTICE 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 emp loyee must be paid total benefits, with credit for earnings and other statutory offsets, from the date the c laim 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 MONTH DAY YEAR NAME OF DECEASED EMPLOYEE injury while working for . EMPLOYER NAME 2. The injury occurred . DESCRIBE HOW THE INJURY HAPPENED 3. Death resulted o n . MONTH DAY YEAR 4. Dependents of deceased employee: T HEREFORE, the petitioner asks the board to order benefits pursuant to Title 39 or 39-A. ____________________________________________________ ______ SIGNATURE 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 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 r equest. For assistance with this form, contact the ADA Coordinator at the Maine W orkers’ Compensation Board. Telephone: (888) 801-9087 or TTY Maine Relay 711 . W CB -150 (eff. 1/1/13 ) Name Date of Birth Relationship to Deceased