Can the petition be e-signed?

Yes — electronic signatures are legally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted; verify tribunal rules and any exceptions that require original ink or notarization.

What signature method is safest?

Use an auditable e-signature with authentication and a preserved audit trail; for especially sensitive filings, consider notarization or RON per local rules.

Who may sign the petition?

The claimant or authorized representative signs. Counsel may sign on behalf of a client if local rules permit, and representative authority should be documented.

How do I correct a filed petition?

File an amended petition or motion to correct per tribunal procedure; include a clear statement of the correction and serve all parties promptly.

Is notarization required?

Notarization depends on the forum and document type; check local tribunal rules—some jurisdictions accept unsworn verified statements while others require notarized verification.

What if a party objects to the impairment rating?

The respondent may request an independent medical examination or dispute the methodology; expect evidentiary hearings and expert testimony to resolve rating disputes.

Electronic Signature
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Petition to Determine Extent of Permanent Impairment

Petition to Determine Extent of Permanent Impairment

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

PETITION TO DETERMINE EXTENT OF PERMANENT IMPAIRMENT

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:

1. On sustained a work-related injury while working for

2. The injury resulted in % whole person permanent impairment.

THEREFORE, the petitioner asks the board to determine the extent of permanent impairment.

SIGNATURE OF PETITIONER

DATED:

FILING INSTRUCTIONS

Mail original petition to the Workers' Compensation Board at the above address by regular mail.
Mail one (1) copy by certified mail, return receipt requested to each other party named in the petition.
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 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 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-180 (eff. 1/1/13)

What this Petition Is and when it’s used

A Petition to Determine Extent of Permanent Impairment is a legal filing typically used in workers’ compensation or disability matters to request an official finding of the claimant’s permanent impairment percentage. The petition summarizes medical evidence, documents treatment history, identifies the treating providers, and asks the deciding body—an administrative judge, magistrate, or board—to adopt an impairment rating under the applicable medical guidelines. Accurate completion focuses the record, narrows disputes over benefits or apportionment, and creates a clear procedural pathway for hearings, independent medical examinations, or disability rating panels.

Why a precise petition matters

A correctly prepared petition frames the legal and medical issues for decision-makers, limits surprise disputes, and preserves the claimant’s right to appropriate benefits. Clear facts and supporting evidence reduce procedural delays and help the tribunal apply the correct rating schedule and statutory standards.

Who typically files or responds to this petition

Parties involved include injured workers, employers, insurers, and their counsel or claims representatives; medical providers supply supporting reports.

Claimants and counsel — File to establish impairment for benefits or future medical care entitlement.
Employers and insurers — Respond to challenge or request independent medical evaluation and apportionment analysis.
Treating physicians — Provide objective impairment ratings and documentation supporting the claimed percentage.

Each participant has distinct responsibilities: the filer assembles evidence, respondents may object or request IME, and providers must document functional limitations.

Core sections that must appear in a professional petition

A professional petition organizes the case facts, medical record, legal basis, requested relief, and signature blocks so the decision-maker can evaluate impairment without follow-up requests.

Caption

Case title, docket or claim number, parties, insurer, and jurisdiction identifying the administrative forum.

Statement of Facts

Concise chronology: date of injury, mechanism, prior conditions, course of treatment, and any prior impairment findings or settlements.

Medical Evidence

List of records and reports attached, including dates, providers, objective findings, tests, and the treating physician’s impairment percentage and methodology.

Legal Basis

Statutory or regulatory citations supporting the request for impairment determination and method (medical schedule or AMA guides).

Relief Requested

Precise request (e.g., find X% whole-person impairment effective MM/DD/YYYY and award related benefits or adjustments).

Verification & Signatures

Signed declaration under penalty of perjury, date, contact information, and counsel identification if applicable.

Step-by-step to complete the petition

Follow these steps in order to compile, verify, and submit a complete petition that meets procedural and evidentiary expectations.

01

Gather Records: Collect all relevant medical and billing records, diagnostic studies, and prior ratings.
02

Draft Petition: Complete caption, facts, legal basis, and precise relief requested.
03

Attach Evidence: Append provider reports, test results, and any supporting declarations or exhibits.
04

Sign & Verify: Signer signs, dates, and includes contact information; notarize if required.

How to configure an online petition workflow

When filing electronically, set fields and routing to capture signatures, dates, and attachments reliably and to preserve an admissible audit trail.

Field	Configuration
Claimant Signature Field	Required; date stamp; signer authentication recommended
Provider Attachment Slot	Enable PDF uploads and name files with provider/date
Routing Order	File to tribunal then serve insurer and respondents
Audit Trail Capture	Record IP, timestamp, and signer identity method

Where the petition goes and what happens next

After filing, the clerk or claims unit assigns it for review; respondents may answer or request an IME, and the matter proceeds to hearing or administrative determination.

Clerk Intake: Clerk logs petition and assigns docket number.
Service to Parties: Respondents are served and given statutory time to respond.
Prehearing Steps: Scheduling, exchange of records, and potential IME ordered.
Final Determination: Hearing or stipulated rating adopted by order.

Digital signing and e-submission considerations

Ensure the e-signature platform captures intent, attribution, and retention to meet ESIGN/UETA standards and tribunal rules.

Authentication: Use email or SMS verification, or stronger methods for sensitive records
Audit Trail: Preserve timestamps, IP addresses, and activity logs
File Formats: Accept PDFs and keep signed PDF/A copies

Verify the tribunal accepts electronic filings; if not, print and file a paper copy per local rules and retain the signed digital record for service.

Common timing and filing windows to note

Respect tribunal deadlines for filing, serving, and responding; specific timeframes depend on the forum and governing statute of limitations.

Filing Deadline:

Statutes of limitations and notice rules vary by state; verify applicable statute.

Service Deadline:

Many forums require prompt service after filing—check local procedural rules.

Response Period:

Respondents commonly have 20–30 days to answer, subject to local rules.

IME Scheduling:

IME often scheduled within 30–90 days after petition or answer.

Hearing Dates:

Hearing scheduling depends on case backlog; plan for weeks to months.

Common mistakes that delay resolution

Incomplete medical exhibits: omitting test results or dated provider summaries forces additional records requests and delays adjudication.
Wrong caption or claim number: filing under an incorrect docket leads to administrative rejection or misrouting of the petition.
Unclear impairment methodology: failing to state the rating method (AMA Guides edition or statutory schedule) invites dispute about admissibility.
Missing service or verification: forgetting required service steps or a signed verification can result in dismissal or denial on procedural grounds.

Consequences of an incorrect or late petition

Dismissal Risk: Procedural defects may cause denial or dismissal.

Statute Bar: Late filing can foreclose relief under applicable limitations.

Evidentiary Loss: Missing attachments may forfeit critical proof.

Fee Exposure: Some forums assess filing or sanction fees for improper filings.

Reputational Harm: Repeated errors may weaken credibility at hearing.

Benefit Reduction: Incorrect ratings can reduce future compensation entitlements.

eSignature vendor comparison relevant to petition filing

Compare base pricing and key compliance features when choosing an e-signature platform for sensitive legal filings; signNow appears first for reference.

	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 free trial	Varies by offer	Varies by offer	Varies by offer	Varies by offer
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about filing and signing the petition

Answers to common procedural and signature questions to help avoid rejections, preserve admissibility, and comply with electronic signature rules.

Need help? Contact support

Can the petition be e-signed?
Yes — electronic signatures are legally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted; verify tribunal rules and any exceptions that require original ink or notarization.
What signature method is safest?
Use an auditable e-signature with authentication and a preserved audit trail; for especially sensitive filings, consider notarization or RON per local rules.
Who may sign the petition?
The claimant or authorized representative signs. Counsel may sign on behalf of a client if local rules permit, and representative authority should be documented.
How do I correct a filed petition?
File an amended petition or motion to correct per tribunal procedure; include a clear statement of the correction and serve all parties promptly.
Is notarization required?
Notarization depends on the forum and document type; check local tribunal rules—some jurisdictions accept unsworn verified statements while others require notarized verification.
What if a party objects to the impairment rating?
The respondent may request an independent medical examination or dispute the methodology; expect evidentiary hearings and expert testimony to resolve rating disputes.

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