Fill and Sign the Petition to Remedy Discrimination Mainegov Form

PETITION TO REMEDY DISCRIMINATION 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: W ORKERS’ COMPENSATION INSURER (NOTICE ONLY) SOCIAL SECURITY NUMBER: XXX-XX- (only last four digits required) BOARD FILE NUMBER: NAME: STREET/P.O. BOX: CITY, STATE, ZIP: 1. On , alleged a work-related MONTH DAY YEAR EMPLOYEE NAME injury while working for . EMPLOYER NAME 2. The above- named employer discriminated against the employee for testifying or asserting a claim under Title 39-A in the following ways (explain how the employer discriminated): TH EREFORE, the employee asks the board to order relief pursuant to 39-A M.R.S.A. §353. __________________________________________________________ SIGNATURE OF PETITIONER FILING INSTRUCTIONS 1. Mail original petition to t h e 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 ca rds whe n 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 -195 (eff. 1/1/13)