Form WCB-240 "Notice of Intent to Appeal" - Maine

What Is Form WCB-240?

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 September 1, 2018;
  • 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;

Download a fillable version of Form WCB-240 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-240 "Notice of Intent to Appeal" - Maine

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NOTICE OF INTENT TO APPEAL
STATE OF MAINE
WORKERS' COMPENSATION BOARD
APPELLATE DIVISION
27 STATE HOUSE STATION
AUGUSTA, MAINE 04333
CHECK ONE:
CASE NAME:
APPELLANT HAS ORDERED TRANSCRIPT
WCB FILE# or AIU CASE#:
FROM ___________________________________
(please notify Appellate Division when you receive transcript)
ISSUANCE DATE OF DECISION:
TRANSCRIPT HAS ALREADY BEEN PREPARED
MAIL DATE OF DECISION:
REQUEST HAS BEEN MADE TO REGIONAL OFFICE TO
ORDER TRANSCRIPT
APPELLANT:
APPELLEE:
COUNSEL NAME:
COUNSEL NAME:
REPRESENTING:
REPRESENTING:
STREET/P.O. BOX:
STREET/P.O. BOX:
CITY, STATE, ZIP:
CITY, STATE, ZIP:
TELEPHONE NUMBER:
TELEPHONE NUMBER:
E-MAIL:
E-MAIL:
Please include the same information about additional parties on a separate sheet.
NOTICE
A party in interest may file with the Appellate Division a notice of appeal of a decision by an Administrative Law Judge pursuant
to 39-A M.R.S.A. §318 within 20 days after receipt of notice of issuance of the decision by the Administrative Law Judge. When
filing this notice, the appellant also shall file with the clerk a copy of the decision appealed.
1. On
,
received notice of the issuance of a
MONTH
DAY
YEAR
APPELLANT NAME
decision by Administrative Law Judge
in the above captioned case.
ADMINISTRATIVE LAW JUDGE NAME
2. The appellant appeals the following issue(s):
THEREFORE, the appellant asks the Appellate Division to review the decision pursuant to 39-A M.R.S.A. §321-B.
__________________________________________________________
DATED:
SIGNATURE OF APPELLANT
MONTH
DAY
YEAR
FOR HAND DELIVERIES OR NON-POSTAL SERVICE CARRIERS:
FILING INSTRUCTIONS
442 Civic Center Drive, Suite 100
1.
Mail original notice to the clerk of the Appellate Division at the above
Augusta, ME 04330
address by regular mail, or hand deliver to any regional Board office.
2.
Mail one (1) copy to each other party named above.
3.
Keep one (1) copy for yourself.
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-240 (eff. 9/1/18)
NOTICE OF INTENT TO APPEAL
STATE OF MAINE
WORKERS' COMPENSATION BOARD
APPELLATE DIVISION
27 STATE HOUSE STATION
AUGUSTA, MAINE 04333
CHECK ONE:
CASE NAME:
APPELLANT HAS ORDERED TRANSCRIPT
WCB FILE# or AIU CASE#:
FROM ___________________________________
(please notify Appellate Division when you receive transcript)
ISSUANCE DATE OF DECISION:
TRANSCRIPT HAS ALREADY BEEN PREPARED
MAIL DATE OF DECISION:
REQUEST HAS BEEN MADE TO REGIONAL OFFICE TO
ORDER TRANSCRIPT
APPELLANT:
APPELLEE:
COUNSEL NAME:
COUNSEL NAME:
REPRESENTING:
REPRESENTING:
STREET/P.O. BOX:
STREET/P.O. BOX:
CITY, STATE, ZIP:
CITY, STATE, ZIP:
TELEPHONE NUMBER:
TELEPHONE NUMBER:
E-MAIL:
E-MAIL:
Please include the same information about additional parties on a separate sheet.
NOTICE
A party in interest may file with the Appellate Division a notice of appeal of a decision by an Administrative Law Judge pursuant
to 39-A M.R.S.A. §318 within 20 days after receipt of notice of issuance of the decision by the Administrative Law Judge. When
filing this notice, the appellant also shall file with the clerk a copy of the decision appealed.
1. On
,
received notice of the issuance of a
MONTH
DAY
YEAR
APPELLANT NAME
decision by Administrative Law Judge
in the above captioned case.
ADMINISTRATIVE LAW JUDGE NAME
2. The appellant appeals the following issue(s):
THEREFORE, the appellant asks the Appellate Division to review the decision pursuant to 39-A M.R.S.A. §321-B.
__________________________________________________________
DATED:
SIGNATURE OF APPELLANT
MONTH
DAY
YEAR
FOR HAND DELIVERIES OR NON-POSTAL SERVICE CARRIERS:
FILING INSTRUCTIONS
442 Civic Center Drive, Suite 100
1.
Mail original notice to the clerk of the Appellate Division at the above
Augusta, ME 04330
address by regular mail, or hand deliver to any regional Board office.
2.
Mail one (1) copy to each other party named above.
3.
Keep one (1) copy for yourself.
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-240 (eff. 9/1/18)