Fill and Sign the Petition to Determine Extent of Permanent Impairment Form

PETITION TO DETERMINE EXTENT OF PERMANENT IMPAIRMENT 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: 1. On , sustained a work-related MONTH DAY YEAR EMPLOYEE NAME injury while working for . EMPLOYER NAME 2. The injury resulted in % whole person permanent impairment. T HEREFORE, the petitioner asks the board to determine the extent of permanent impai rment. __________________________________________________________ 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, ret urn 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 T he 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 orkers’ Compensation Board. Telephone: (888) 801-9087 or TTY Maine Relay 711. W CB -180 (eff. 1/1/13)