EMPLOYEE PETITION FOR REVIEW OF INCAPACITY
AND REQUEST FOR PROVISIONAL ORDER, WCB-121
An injured employee or their representative may file this petition to
request a determination of the injured employee’s entitlement to
ongoing weekly compensation and to request a Provisional Order to reinstate
their weekly benefits when they disagree with the employer/insurer’s
reduction or discontinuance of those benefits.
Distribution
The Employee Petition for Review of Incapacity and Request for Provisional
Order, WCB-121, is to be distributed as follows:
Original Mail the original petition to the Workers’ Compensation
Board at the following address by regular mail:
State of Maine
Workers’ Compensation Board
27 State House Station
Augusta, Maine 04333-0027
Copy 1 Mail one copy of the petition by certified mail, return receipt
requested to the insurance company or 3rd-party administrator (if there
is an insurance company or 3rd-party administrator representing the employer).
Copy 2 Mail one copy of the petition by certified mail, return receipt
requested to the employer.
Copy 3 Keep one copy of the petition for your records. Also keep the
green certified mail cards (for the copies sent to the insurance company
or 3rd‑party administrator and the employer) when the U.S. Post
Office returns them to you.
INSTRUCTIONS FOR COMPLETING EMPLOYEE PETITION FOR REVIEW
OF INCAPACITY AND REQUEST FOR PROVISIONAL ORDER, WCB-121
Employee
Name
Enter the injured employee’s first name, middle initial and last
name.
Street/P.O. Box
Enter the injured employee’s mailing address.
City, State, Zip
Enter the city, state and zip code of the injured employee’s mailing
address.
Telephone Number
Enter the injured employee’s home telephone number, including the
area code.
Employee Social Security Number
Enter the injured employee’s social security number.
Board File Number
If you know the file number assigned by the Workers’ Compensation
Board, enter it here.
Employer
Name
Enter the employer’s name.
Street/P.O. Box
Enter the employer’s mailing address.
City, State, Zip
Enter the city, state and zip code of the employer’s mailing address.
Insurance Company
Name
Enter the name of the insurance company or 3rd-party administrator (if
there is one) who represents the employer’s interest in this
workers’ compensation claim.
Street/P.O. Box
Enter the insurance company or 3rd-party administrator’s mailing
address.
City, State, Zip
Enter the city, state and zip code of the insurance company or 3rd-party
administrator’s mailing address.
On ___/___/____, ________ experienced a work-related injury while working
for ________.
MM DD YYYY Employee Name Employer Name
Enter the date (month, day, year) of the employee’s injury on the
first line.
Enter the injured employee’s name (first name, middle initial and
last name) on the second line.
Enter the employer’s name on the third line.
Compensation of $_____ per week is being paid for _______________ incapacity.
Partial, Total (Select One)
Enter the dollar amount of the weekly workers’ compensation benefit
currently being received by the injured employee on the first line. If
the weekly benefit differs from week to week, enter the word “varying” on
this line.
If the amount shown on the first line represents the full amount of benefits
allowed for a full week of lost earnings, enter the word “total” on
the second line. If the amount shown on the first line does not represent
the full amount of benefits allowed for a full week of lost earnings,
enter the word “partial” on this line. If the amount shown
on the first line is $0.00, do not complete this line.
Compensation benefits were ____________________________ as of ___/___/____.
Reduced, Discontinued (Select One) MM DD YYYY
Enter the word (reduced or discontinued) which best describes the change
in the injured employee’s weekly benefits that has prompted the
filing of this form on the first line.
Enter the effective date (month, day, year) of the reduction or discontinuance
of weekly benefits on the second line.
The employer should reinstate the employee’s weekly compensation
benefits for the following reasons:
Enter the reason(s) why you believe that the injured employee’s
benefits should be restored. Attach copies of any recent medical reports
and/or other documents that support this petition.
____________________________
Signature of Employee
This line must be signed by the injured employee or their representative.
Dated: ___/___/____
MM DD YYYY
Enter the date (month, day, year) that this form was signed by the injured
employee or their representative.
______________________________
Name of Employee’s Attorney or Advocate (If Any)
If the injured employee is represented by an attorney or advocate, enter
the name of the employee’s attorney or advocate.
______________________________
Street/P.O. Box
Enter the attorney or advocate’s mailing address.
______________________________
City, State, Zip
Enter the city, state and zip code of the attorney or advocate’s
mailing address.
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