Fill and Sign the Petition for Payment of Medical and Related Services Wcb Form

PETITION FOR RESTORATION 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. On , sustained a work -related MONTH DAY YEAR EMPLOYEE NAME injury while working for . EMPLOYER NAME 2 . The injury occurred DESCRIBE HOW THE INJURY HAPPENED and the employee injured his/her . LIST BODY PARTS INJURED 3. Compensation of $ per week was being paid for incapacity. PARTIAL, TOTAL (SELECT ONE) 4. Co mpensation benefits were discontinued as of . MONTH DAY YEAR 5. As of , the employee experienced a new period of incapacity . MONTH DAY YEAR PARTIAL / TOTAL (INSERT ONE) TH EREFORE, the employee asks the board to order the restoration of benefits pursu ant 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 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. A uxiliary aids and services are available to individuals with disabilities upon request. 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 -170 (eff. 1/1/13 )