PETITION FOR AWARD OF COMPENSATION – FATAL,
WCB-150
Any interested party may file this petition to request a determination
of an employer’s responsibility for the payment of compensation
to the dependent(s) of an injured employee who has died as a result of
their work-related injury.
This petition may be filed no later than one year after the employee’s
death.
Distribution
The Petition for Award of Compensation - Fatal, WCB-150, 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 – FATAL, WCB-150
Petitioner
Name
Enter the first name, middle initial and last name of the person filing
this petition. (This is usually either the dependent or their legal
guardian.)
Street/P.O. Box
Enter the petitioner’s mailing address.
City, State, Zip
Enter the city, state and zip code of the petitioner’s mailing
address.
Telephone Number
Enter the petitioner’s telephone number, including the area code.
Employee Social Security Number
Enter the deceased 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
MM DD YYYY Name of Deceased Employee
working for ______________.
Employer Name
Enter the date (month, day, year) of the deceased employee’s injury
on the first line.
Enter the deceased 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 happened.
Death resulted on: ___/___/____.
MM DD YYYY
Enter the date (month, day, year) of the injured employee’s death.
Petitioner relationship:
Enter the relationship of the petitioner (listed above) to the deceased
employee. For example: spouse, ex-spouse, child, parent, sibling, friend,
attorney, etc.
List the dependent(s) and respective date(s) of birth:
Enter the name(s) and date(s) of birth of the person(s) who was/were
financially dependent upon the injured employee at the time of his/her
death.
____________________________
Signature of Petitioner
This line must be signed by the petitioner or their representative.
Dated: ___/___/____
MM DD YYYY
Enter the date (month, day, year) that this form was signed by the petitioner
or their representative.
______________________________
Name of Petitioner’s Attorney or Advocate (If Any)
If the petitioner is represented by an attorney or advocate, enter the
name of the petitioner’s attorney or advocate.
______________________________
Street/P.O. Box
Enter the attorney or advocate’s mailing address.
______________________________
City, State, Zip
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