Maine > Workers Compensation
Petition For Award Of Compensation - Occupational Disease Law WCB-160 - Maine
| Petition For Award Of Compensation - Occupational Disease Law Form. This is a Maine form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
PETITION FOR AWARD OF COMPENSATION - OCCUPATIONAL DISEASE LAW 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 NOTICE $ SDUW\ LV QRW UHTXLUHG WR ILOH D ZULWWHQ UHVSRQVH WR WKLV SHWLWLRQ XQGHU $ 056$ 8SRQ QRWLFH RI D FODLP IRU LQFDSDFLW\ RU GHDWK EHQHILWV KRZHYHU WKH HPSOR\HULQVXUHU PXVW FRPSO\ ZLWK WKH SURYLVLRQV RI 0$5 &K RU WKH HPSOR\HH PXVW EH SDLG WRWDO EHQHILWV ZLWK FUHGLW IRU HDUQLQJV DQG RWKHU VWDWXWRU\ RIIVHWV IURP WKH GDWH WKH FODLP LV PDGH LQ DFFRUGDQFH ZLWK $ 056$ DQG LQ FRPSOLDQFH ZLWK $ 056$ 'DWH RI LQFDSDFLW\ 0217+ '$< <($5 0217+ '$< <($5 'DWH HPSOR\HH JDYH QRWLFH RI LQFDSDFLW\ 'DWH RI ODVW H[SRVXUH 0217+ '$< <($5 <($5 'DWH HPSOR\PHQW FHDVHG 7KH H[SRVXUH RFFXUUHG DQG WKH HPSOR\HH GHYHORSHG 0217+ '$< '(6&5,%( +2: 7+( (;32685( +$33(1(' '(6&5,%( 7+( 1$785( 2) 7+( 2&&83$7,21$/ ',6($6( 7+(5()25( WKH HPSOR\HH DVNV WKH ERDUG WR RUGHU EHQHILWV SXUVXDQW WR 7LWOH RU $ 3DUW 2FFXSDWLRQDO 'LVHDVH /DZ 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
|
|||||||
