Fill and Sign the Petition for Award of Compensation Mainegov Form

PETITION FOR AWARD OF COMPENSATION - OCCUPATIONAL DISEASE LAW 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 NUMBER: 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: 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. Date of incapacity: . MONTH DAY YEAR 2. Date employee gave notice of incapacity: . MONTH DAY YEAR 3. Date of last exposure: . MONTH DAY YEAR 4. Date employment ceased: . MONTH DAY YEAR 5. The exposure occurred DESCRIBE HOW THE EXPOSURE HAPPENED and the employee developed . DESCRIBE THE NATURE OF THE OCCUPATIONAL DISEASE TH EREFORE, the employee asks the board to order benefits pursuant to Title 39 or 39-A, Part 2 (Occupational Disease Law) . __________________________________________________________ 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 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 disabili ties 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 -160 (eff. 1/1/13)