Maine > Workers Compensation
Complaint For Penalties WCB-280 - Maine
| Complaint For Penalties Form. This is a Maine form and can be used in Workers Compensation . |
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&203/$,17 )25 3(1$/7,(6 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 . EMPLOYER NAME work-related injury while working for 2. On MONTH DAY YEAR , the employer had notice or knowledge of the work-related injury. . MONTH DAY YEAR Incapacity (lost time from work) began on 3. [&+(&. 21(@ There is no ongoing dispute regarding the claim and the insurer/employer has failed to pay weekly compensation benefits within thirty (30) days after becoming due and payable; OR The insurer/employer failed to deny the claim within fourteen (14) days after notice or knowledge of the injury and has failed to pay weekly compensation benefits within thirty (30) days of becoming due and payable. 7+(5()25(, I request such penalties as I may be entitled pursuant to Title 39-A §205(3). 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 $1' if it is not a party, mail one (1) copy to the employer, employers' insurer or group selfinsurer. 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 3. 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\ :&% HII American LegalNet, Inc. www.FormsWorkFlow.com
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