Complaint For Penalties Pursuant {WCB-410} | Pdf Fpdf Docx | Maine

 Maine   Workers Compensation 
Complaint For Penalties Pursuant {WCB-410} | Pdf Fpdf Docx | Maine

Last updated: 9/22/2023

Complaint For Penalties Pursuant {WCB-410}

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Description

WCB-410 - COMPLAINT FOR PENALTIES 39-A §205(4). This form is used by an employee or health care provider in the State of Maine to request penalties against an employer or insurer for failing to pay medical or health care bills related to a work-related injury. This complaint is submitted to the Workers’ Compensation Board’s Abuse Investigation Unit when the responsible insurer or employer has not paid submitted medical bills within thirty days after being properly notified by certified mail. The form requires the petitioner to provide details about the injury, billing, and proof of certified mailing, and it affirms that no dispute currently exists regarding the underlying claim. www.FormsWorkflow.com

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