Maine > Workers Compensation
Petition To Determine Average Weekly Wage WCB-122 - Maine
| Petition To Determine Average Weekly Wage Form. This is a Maine form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
PETITION TO DETERMINE AVERAGE WEEKLY WAGE 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 LQMXU\ ZKLOH ZRUNLQJ IRU 7KH SDUWLHV KDYH QRW DJUHHG WR DQ DYHUDJH ZHHNO\ ZDJH IRU WKLV GDWH RI LQMXU\ 7+(5()25( WKH SHWLWLRQHU DVNV WKH ERDUG WR GHWHUPLQH WKH FRUUHFW DYHUDJH ZHHNO\ ZDJH 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) 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
|
|||||||
