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Home >Board Forms> Petition for Award of Compensation - Occupational Disease Law Instructions

PETITION FOR AWARD OF COMPENSATION – OCCUPATIONAL DISEASE LAW, WCB-160

An injured employee or their representative may file this petition to request a determination of an employer’s responsibility for the payment of compensation related to the employee’s occupational disease.

Distribution

The Petition for Award of Compensation – Occupational Disease Law, WCB-160, 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 –OCCUPATIONAL DISEASE LAW, WCB-160

 

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.

  1. On ___/___/____, ________ developed a work-related disease while working for ________.      MM    DD   YYYY    Employee
    Name                                                                                                           Employer Name
    Enter the date (month, day, year) of the onset of the employee’s occupational disease 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.
  1. Date of last exposure: ___/___/____

    MM    DD   YYYY
    Enter the last date (month, day, year) that the injured employee was exposed to the cause or condition from which the occupational disease arose.
  2. Date of Incapacity: ___/___/____

    MM    DD    YYYY
    Enter the date (month, day, year) of the first day (partial or full) lost from work because of the occupational disease.
  3. Date employment ceased: ___/___/____

    MM   DD    YYYY
    Enter the date (month, day, year) that the injured employee stopped working for the employer listed above.
  4. Describe how the exposure occurred:
    Enter a brief description of the events or conditions that caused the employee to be exposed to the cause or condition from which the occupational disease arose.
  5. Describe the occupational disease:
    Enter a brief description of the occupational disease (asbestosis, silicosis, occupational hearing loss, etc.).
  6. List the body part(s) affected:

Enter the name(s) of the body part(s) (right eye, left lung, etc.) affected by the occupational disease.

____________________________
                    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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