PETITION TO REMEDY DISCRIMINATION, WCB-195
An injured employee or their representative may file this petition to
request a determination regarding allegations of discrimination against
the employee by the employer because of a work‑related injury.
Distribution
The Petition to Remedy Discrimination, WCB-195, 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 REMEDY DISCRIMINATION, WCB-195
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.
- The above-named employer discriminated against me as a result of
a work-related injury on: ___/___/____
MM DD YYYY
Enter the date (month, day, year) of the work-related injury.
- Explain
how the employer discriminated:
Enter a brief description of the employer’s discriminatory action(s)
against the injured employee.
WHEREFORE, the employee asks the Board to order the following benefits
pursuant to 39‑A M.R.S.A. §353 (check all that apply):
___ Back wages
___ Reinstatement to my former position or any other available position
for which
I am qualified and physically able to perform
___ Reestablishment of my employee benefits
___ Payment of reasonable attorney fees
Place a checkmark on all lines that describe the remedies for discrimination
that you are seeking.
_________________________
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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