Form WCB-121 "Employee Petition for Review of Incapacity and Request for Provisional Order" - Maine

What Is Form WCB-121?

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-121 by clicking the link below or browse more documents and templates provided by the Maine Workers' Compensation Board.

ADVERTISEMENT
ADVERTISEMENT

Download Form WCB-121 "Employee Petition for Review of Incapacity and Request for Provisional Order" - Maine

Download PDF

Fill PDF online

Rate (4.5 / 5) 20 votes
Page background image
EMPLOYEE PETITION FOR REVIEW OF INCAPACITY
AND REQUEST FOR PROVISIONAL ORDER
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:
1. On
,
sustained a work-related
MONTH
DAY
YEAR
EMPLOYEE NAME
injury while working for
.
EMPLOYER NAME
2. Compensation of $
per week is being paid for
incapacity.
PARTIAL / TOTAL (INSERT ONE)
3. Compensation benefits were
as of
.
REDUCED / DISCONTINUED (INSERT ONE)
MONTH
DAY
YEAR
4. The employer should reinstate the employee’s weekly compensation benefits for the following reasons:
(Attach recent medical reports and/or other documents to support this petition.)
THEREFORE, the employee asks that the board issue a provisional order reinstating compensation benefits pursuant to
39-A M.R.S.A. §205.
__________________________________________________________
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
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-121 (eff. 1/1/13)
EMPLOYEE PETITION FOR REVIEW OF INCAPACITY
AND REQUEST FOR PROVISIONAL ORDER
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:
1. On
,
sustained a work-related
MONTH
DAY
YEAR
EMPLOYEE NAME
injury while working for
.
EMPLOYER NAME
2. Compensation of $
per week is being paid for
incapacity.
PARTIAL / TOTAL (INSERT ONE)
3. Compensation benefits were
as of
.
REDUCED / DISCONTINUED (INSERT ONE)
MONTH
DAY
YEAR
4. The employer should reinstate the employee’s weekly compensation benefits for the following reasons:
(Attach recent medical reports and/or other documents to support this petition.)
THEREFORE, the employee asks that the board issue a provisional order reinstating compensation benefits pursuant to
39-A M.R.S.A. §205.
__________________________________________________________
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
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-121 (eff. 1/1/13)