PETITION FOR AWARD OF COMPENSATION, WCB-140
Any interested party may file this petition to request a determination
of an employer’s responsibility for the payment of compensation
to an injured employee (§305).
Use the following instructions only when this form is being prepared
and filed by the injured employee or their representative.
(For employer or employer representative instructions, please contact
a Claims
Resolution Specialist at the nearest office of the Workers’ Compensation
Board.)
Distribution
The Petition for Award of Compensation, WCB-140, 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
FOR AWARD OF COMPENSATION, WCB-140
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.
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.
Describe how the injury occurred:
Enter a brief description of how the injury occurred.
List body part(s) injured:
Enter a list of the body parts affected by the injury or illness. When
specifying a part of the body, be sure to indicate whether it is “left” or “right.” When
the injury involves fingers or toes, use the numbers one through five
to describe the body part. (One is the thumb or big toe; five is the
little finger or little toe.)
The employee_______________ lose time from work.
Did, Did Not (Select One)
If the injured employee has lost a day or more from work, enter “did.” If
the injured employee has not lost a day or more from work, enter “did
not.”
WHEREFORE, the petitioner asks the Board to order the following benefits
pursuant to 39‑A M.R.S.A. (check all that apply):
___ Weekly lost time benefits
___ Protection of the Act
___ Specific loss benefits
If the injured employee has been incapacitated for more than seven days,
check “Weekly lost time benefits.”
If the injured employee seeks to protect their rights under the Workers’ Compensation
Act, check “Protection of the Act.”
If the injured employee has suffered a dismemberment or the total loss
of an eye due to the work-related injury, check “Specific loss
benefits.”
____________________________
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.
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