Maine > Workers Compensation
Petition For Award Of Compensation WCB-140 - Maine
| Petition For Award Of Compensation Form. This is a Maine form and can be used in Workers Compensation . |
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PETITION FOR AWARD OF COMPENSATION 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$ 2Q 0217+ '$< <($5 (03/2<(( 1$0( (03/2<(5 1$0( VXVWDLQHG D ZRUNUHODWHG LQMXU\ ZKLOH ZRUNLQJ IRU 7KH HPSOR\HH JDYH QRWLFH RI LQFDSDFLW\ IURP ZRUN IRU KLVKHU ZRUNUHODWHG LQMXU\ RQDERXW 7KH LQMXU\ RFFXUUHG DQG WKH HPSOR\HH LQMXUHG KLVKHU 7KH HPSOR\HH ORVH WLPH IURP ZRUN 0217+ '$< <($5 '(6&5,%( +2: 7+( ,1-85< +$33(1(' /,67 %2'< 3$576 ,1-85(' ',' ',' 127 ,16(57 21( 7+(5()25( WKH HPSOR\HH DVNV WKH ERDUG WR RUGHU EHQHILWV SXUVXDQW WR 7LWOH RU $ 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\ :&% HII American LegalNet, Inc. www.FormsWorkFlow.com
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