PETITION TO DETERMINE AVERAGE WEEKLY WAGE, WCB-122
Any interested party may file this petition to request a determination
of the injured employee’s average weekly wage.
Use the following instructions only when this form is being prepared
and filed by the injured employee or their representative.
(Instructions for the employer or their representative begin on page
123.)
Distribution
The Petition to Determine Average Weekly Wage, WCB-122, 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 PETITION TO
DETERMINE AVERAGE WEEKLY WAGE, WCB-122
Petitioner
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.
EDI users must complete this line.
Respondent
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.
Respondent
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.
____________________________
Signature of Petitioner
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 Petitioner’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.
Use the following instructions only when this form is being prepared
and filed
by the employer, insurer, 3rd-party administrator, or their representative.
(Instructions for the employee or their representative begin on page
121.)
Distribution
The Petition to Determine Average Weekly Wage, WCB-122, 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 injured employee.
Copy 2 If this petition is being filed by the insurer, 3rd-party administrator,
employer attorney or employer advocate, mail one copy of the petition
by certified mail, return receipt requested to the employer.
Copy 3 If the employee is represented by an attorney or advocate, mail
one copy of the petition by certified mail, return receipt requested
to the attorney or advocate.
Copy 4 Keep one copy of the petition for your records. Also keep the
green certified mail cards (for the copies sent to the employee, employer
and the employee’s attorney) when the U.S. Post Office returns
them to you.
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