Maine > Workers Compensation
Employee Petition For Review Of Incapacity And Request For Provisional Order WCB-121 - Maine
| Employee Petition For Review Of Incapacity And Request For Provisional Order Form. This is a Maine form and can be used in Workers Compensation . |
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EMPLOYEE PETITION FOR REVIEW OF INCAPACITY AND REQUEST FOR PROVISIONAL ORDER 67$7( 2) 0$,1( :25.(56' &203(16$7,21 %2$5' 67$7( +286( 67$7,21 $8*867$ 0$,1( (03/2<(( 1$0( 675((732 %2; &,7< 67$7( =,3 7(/(3+21( 180%(5 '$7( 2) %,57+ 62&,$/ 6(&85,7< 180%(5 RQO\ ODVW IRXU GLJLWV UHTXLUHG %2$5' ),/( 180%(5 ;;;;; 1$0( 675((732 %2; &,7< 67$7( =,3 ,1685(5 1$0( 675((732 %2; &,7< 67$7( =,3 (03/2<(5 2Q 0217+ '$< <($5 (03/2<(5 1$0( (03/2<(( 1$0( VXVWDLQHG D ZRUNUHODWHG LQFDSDFLW\ LQMXU\ ZKLOH ZRUNLQJ IRU &RPSHQVDWLRQ RI &RPSHQVDWLRQ EHQHILWV ZHUH SHU ZHHN LV EHLQJ SDLG IRU DV RI 3$57,$/ 727$/ ,16(57 21( 5('8&(' ',6&217,18(' ,16(57 21( 0217+ '$< <($5 7KH HPSOR\HU VKRXOG UHLQVWDWH WKH HPSOR\HH¶V ZHHNO\ FRPSHQVDWLRQ EHQHILWV IRU WKH IROORZLQJ UHDVRQV (Attach recent medical reports and/or other documents to support this petition.) 7+(5()25( WKH HPSOR\HH DVNV WKDW WKH ERDUG LVVXH D SURYLVLRQDO RUGHU UHLQVWDWLQJ FRPSHQVDWLRQ EHQHILWV SXUVXDQW WR $ 056$ BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 6,*1$785( 2) 3(7,7,21(5 '$7(' 0217+ '$< <($5 FILING INSTRUCTIONS 0DLO RULJLQDO SHWLWLRQ WR WKH :RUNHUV¶ &RPSHQVDWLRQ %RDUG DW WKH DERYH DGGUHVV E\ UHJXODU PDLO 0DLO RQH FRS\ by certified mail, return receipt requested WR HDFK RWKHU SDUW\ QDPHG LQ WKH SHWLWLRQ .HHS RQH FRS\ IRU \RXUVHOI DQG NHHS WKH JUHHQ FHUWLILHG PDLO FDUGV ZKHQ UHWXUQHG WR \RX E\ WKH 86 3RVW 2IILFH 1$0( 2) (03/2<(( 6 $77251(< 25 $'92&$7( ,) $1< 675((732 %2; &,7< 67$7( =,3 7(/(3+21( 180%(5 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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