PETITION FOR RESTORATION, WCB-170
An injured employee or their representative may file this petition to
request a determination of the injured employee’s entitlement to
restoration of weekly compensation.
Distribution
The Petition for Restoration, WCB-170, 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 RESTORATION, WCB-170
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.
- Describe how the
injury occurred:
Enter a brief description of how the injury occurred.
- List the 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.)
- Compensation of $ _______ per week was paid for _____________________.
Partial/Total Incapacity (Select One)
Enter the dollar amount of the weekly workers’ compensation benefit
last paid to the injured employee on the first line. If the weekly benefit
differed 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.
- Compensation benefits
were ____________________ as of ___/___/____.
Reduced/Discontinued (Select One) MM DD YYYY
Enter the word (reduced or discontinued) which best describes the last
change in the injured employee’s weekly benefits on the first
line.
Enter the effective date (month, day, year) of the reduction or discontinuance
of weekly benefits on the second line.
- As of ___/___/____, a new period
of _____________________ exists.
MM DD YYYY Partial/Total Incapacity (Select One)
Enter the date (month, day, year) of the onset of the new or increased
period of incapacity on the first line.
Enter the phrase (partial incapacity or total incapacity) which best
describes the new or increased period of incapacity on the second line.
WHEREFORE, the employee asks the Board to order the restoration of the
following benefits pursuant to 39-A M.R.S.A. (check all that apply):
___ Weekly lost time benefits
___ Specific loss benefits
___ Other (please specify)
Check all lines that represent the restored benefits you are seeking.
If you check “Other,” enter a brief description of what that
benefit is.
____________________________
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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