Maine > Workers Compensation

Petition For Review Of Incapacity WCB-120 - Maine

Petition For Review Of Incapacity Form. This is a Maine form and can be used in Workers Compensation .
 Fillable pdf Last Modified 2/15/2013
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PETITION FOR REVIEW OF INCAPACITY 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 (03/2<(5 1$0( 0217+ '$< <($5 (03/2<(( 1$0( VXVWDLQHG D ZRUNUHODWHG LQFDSDFLW\ LQMXU\ ZKLOH ZRUNLQJ IRU &RPSHQVDWLRQ RI 7KH HPSOR\HH¶V LQFDSDFLW\ KDV SHU ZHHN LV EHLQJ SDLG IRU 3$57,$/ 727$/ ,16(57 21( ,1&5($6(' '(&5($6(' (1'(' ,16(57 21( 7+(5()25( WKH SHWLWLRQHU DVNV WKH ERDUG WR UHYLHZ WKH DPRXQW RI FRPSHQVDWLRQ SDLG 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) 3(7,7,21(5 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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