Form WCB-170 "Petition for Restoration" - Maine

What Is Form WCB-170?

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-170 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-170 "Petition for Restoration" - Maine

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PETITION FOR RESTORATION
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:
CITY, STATE, ZIP:
BOARD FILE NUMBER:
NOTICE
A party is not required to file a written response to this petition under 39-A M.R.S.A. §307(3). Upon notice of a claim for
incapacity or death benefits, however, the employer/insurer must comply with the provisions of 90 MAR 351 Ch.1. §1 or the
employee must be paid total benefits, with credit for earnings and other statutory offsets, from the date the claim is made in
accordance with 39-A M.R.S.A. §205(2) and in compliance with 39-A M.R.S.A. §204.
1. On
,
sustained a work-related
MONTH
DAY
YEAR
EMPLOYEE NAME
injury while working for
.
EMPLOYER NAME
2. The injury occurred
DESCRIBE HOW THE INJURY HAPPENED
and the employee injured his/her
.
LIST BODY PARTS INJURED
3. Compensation of $
per week was being paid for
incapacity.
PARTIAL, TOTAL (SELECT ONE)
4. Compensation benefits were discontinued as of
.
MONTH
DAY
YEAR
5. As of
, the employee experienced a new period of
incapacity.
MONTH
DAY
YEAR
PARTIAL / TOTAL (INSERT ONE)
THEREFORE, the employee asks the board to order the restoration of benefits pursuant to Title 39 or 39-A.
__________________________________________________________
DATED:
SIGNATURE OF PETITIONER
MONTH
DAY
YEAR
FILING INSTRUCTIONS
NAME OF EMPLOYEE'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
cards when returned to you by the U.S. Post Office.
TELEPHONE NUMBER
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-170 (eff. 1/1/13)
PETITION FOR RESTORATION
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:
CITY, STATE, ZIP:
BOARD FILE NUMBER:
NOTICE
A party is not required to file a written response to this petition under 39-A M.R.S.A. §307(3). Upon notice of a claim for
incapacity or death benefits, however, the employer/insurer must comply with the provisions of 90 MAR 351 Ch.1. §1 or the
employee must be paid total benefits, with credit for earnings and other statutory offsets, from the date the claim is made in
accordance with 39-A M.R.S.A. §205(2) and in compliance with 39-A M.R.S.A. §204.
1. On
,
sustained a work-related
MONTH
DAY
YEAR
EMPLOYEE NAME
injury while working for
.
EMPLOYER NAME
2. The injury occurred
DESCRIBE HOW THE INJURY HAPPENED
and the employee injured his/her
.
LIST BODY PARTS INJURED
3. Compensation of $
per week was being paid for
incapacity.
PARTIAL, TOTAL (SELECT ONE)
4. Compensation benefits were discontinued as of
.
MONTH
DAY
YEAR
5. As of
, the employee experienced a new period of
incapacity.
MONTH
DAY
YEAR
PARTIAL / TOTAL (INSERT ONE)
THEREFORE, the employee asks the board to order the restoration of benefits pursuant to Title 39 or 39-A.
__________________________________________________________
DATED:
SIGNATURE OF PETITIONER
MONTH
DAY
YEAR
FILING INSTRUCTIONS
NAME OF EMPLOYEE'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
cards when returned to you by the U.S. Post Office.
TELEPHONE NUMBER
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-170 (eff. 1/1/13)