Form WCB-122 "Petition to Determine Average Weekly Wage" - Maine

What Is Form WCB-122?

This is a legal form that was released by the Maine Workers' Compensation Board - a government authority operating within Maine. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2013;
  • The latest edition provided by the Maine Workers' Compensation Board;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WCB-122 by clicking the link below or browse more documents and templates provided by the Maine Workers' Compensation Board.

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Download Form WCB-122 "Petition to Determine Average Weekly Wage" - Maine

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PETITION TO DETERMINE AVERAGE WEEKLY WAGE
STATE OF MAINE
WORKERS' COMPENSATION BOARD
27 STATE HOUSE STATION
AUGUSTA, MAINE 04333-0027
EMPLOYEE
EMPLOYER
NAME:
NAME:
STREET/P.O. BOX:
STREET/P.O. BOX:
CITY, STATE, ZIP:
CITY, STATE, ZIP:
TELEPHONE NUMBER:
DATE OF BIRTH:
INSURER
SOCIAL SECURITY NUMBER: XXX-XX-
NAME:
(only last four digits required)
STREET/P.O. BOX:
BOARD FILE NUMBER:
CITY, STATE, ZIP:
1. On
,
sustained a work-related
MONTH
DAY
YEAR
EMPLOYEE NAME
injury while working for
.
EMPLOYER NAME
2. The parties have not agreed to an average weekly wage for this date of injury.
THEREFORE, the petitioner asks the board to determine the correct average weekly wage pursuant to 39-A M.R.S.A.
§102.
__________________________________________________________
DATED:
SIGNATURE OF PETITIONER
MONTH
DAY
YEAR
FILING INSTRUCTIONS
NAME OF PETITIONER'S ATTORNEY OR ADVOCATE (IF ANY)
1.
Mail original petition to the Workers’ Compensation Board at the
above address by regular mail.
STREET/P.O. BOX
2.
Mail one (1) copy by certified mail, return receipt requested to
each other party named in the petition.
CITY, STATE, ZIP
3.
Keep one (1) copy for yourself and keep the green certified mail
TELEPHONE NUMBER
cards when returned to you by the U.S. Post Office.
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon
request. For assistance with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board. Telephone: (888) 801-9087 or TTY Maine
Relay 711.
WCB-122 (eff. 1/1/13)
PETITION TO DETERMINE AVERAGE WEEKLY WAGE
STATE OF MAINE
WORKERS' COMPENSATION BOARD
27 STATE HOUSE STATION
AUGUSTA, MAINE 04333-0027
EMPLOYEE
EMPLOYER
NAME:
NAME:
STREET/P.O. BOX:
STREET/P.O. BOX:
CITY, STATE, ZIP:
CITY, STATE, ZIP:
TELEPHONE NUMBER:
DATE OF BIRTH:
INSURER
SOCIAL SECURITY NUMBER: XXX-XX-
NAME:
(only last four digits required)
STREET/P.O. BOX:
BOARD FILE NUMBER:
CITY, STATE, ZIP:
1. On
,
sustained a work-related
MONTH
DAY
YEAR
EMPLOYEE NAME
injury while working for
.
EMPLOYER NAME
2. The parties have not agreed to an average weekly wage for this date of injury.
THEREFORE, the petitioner asks the board to determine the correct average weekly wage pursuant to 39-A M.R.S.A.
§102.
__________________________________________________________
DATED:
SIGNATURE OF PETITIONER
MONTH
DAY
YEAR
FILING INSTRUCTIONS
NAME OF PETITIONER'S ATTORNEY OR ADVOCATE (IF ANY)
1.
Mail original petition to the Workers’ Compensation Board at the
above address by regular mail.
STREET/P.O. BOX
2.
Mail one (1) copy by certified mail, return receipt requested to
each other party named in the petition.
CITY, STATE, ZIP
3.
Keep one (1) copy for yourself and keep the green certified mail
TELEPHONE NUMBER
cards when returned to you by the U.S. Post Office.
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon
request. For assistance with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board. Telephone: (888) 801-9087 or TTY Maine
Relay 711.
WCB-122 (eff. 1/1/13)