Maine > Workers Compensation
Petition For Forfeiture WCB-281 - Maine
| Petition For Forfeiture Form. This is a Maine form and can be used in Workers Compensation . |
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3(7,7,21 )25 )25)(,785( 38568$17 72 $ STATE OF MAINE WORKERS' COMPENSATION BOARD ABUSE INVESTIGATION UNIT 27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027 3(7,7,21(5 (03/2<(( NAME: STREET/P.O. BOX: CITY, STATE, ZIP: TELEPHONE NUMBER: DATE OF BIRTH: SOCIAL SECURITY NUMBER: (last four digits required) BOARD FILE NUMBER: NAME: STREET/P.O. BOX: CITY, STATE, ZIP: 5(6321'(17 ,1685(5 NAME: STREET/P.O. BOX: CITY, STATE, ZIP: 5(6321'(17 (03/2<(5 127,&( A party is not required to file a written response to this petition. 39-A M.R.S.A. §307(3). 1. On MONTH DAY YEAR , EMPLOYEE NAME sustained a work-related . injury while working for EMPLOYER NAME 2. On MONTH DAY YEAR , the Workers' Compensation Board: [&+(&. 21(] Issued a decision or order granting a petition and ordering payment of compensation in the amount of $ AMOUNT for the period MONTH DAY YEAR to MONTH DAY YEAR ; OR for AMOUNT Approved an agreement for the payment of compensation in the amount of $ the period MONTH DAY YEAR to MONTH DAY YEAR . 3. The respondent has failed to comply with the Board order or decision or approved agreement by not paying the compensation ordered or agreed to be paid until . MONTH DAY YEAR 7+(5()25(, I request such penalties and attorney's fees as I may be entitled pursuant to Title 39-A §324(2). DATED: MONTH DAY YEAR __________________________________________________________ SIGNATURE OF PETITIONER ),/,1* ,16758&7,216 1. 2. Mail original petition to the Workers' Compensation Board at the above address by regular mail. Mail one (1) copy E\ FHUWLILHG PDLO UHWXUQ UHFHLSW UHTXHVWHG 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 3. TELEPHONE NUMBER 7KH 6WDWH RI 0DLQH SURYLGHV HTXDO RSSRUWXQLW\ LQ HPSOR\PHQW DQG SURJUDPV $X[LOLDU\ DLGV DQG VHUYLFHV DUH DYDLODEOH WR LQGLYLGXDOV ZLWK GLVDELOLWLHV XSRQ UHTXHVW )RU DVVLVWDQFH ZLWK WKLV IRUP FRQWDFW WKH $'$ &RRUGLQDWRU DW WKH 0DLQH :RUNHUV¶ &RPSHQVDWLRQ %RDUG 7HOHSKRQH RU 77< 0DLQH 5HOD\ American LegalNet, Inc. :&% HII www.FormsWorkFlow.com
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