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Home >Board Forms> Request for Expedited Proceeding Instructions

REQUEST FOR EXPEDITED PROCEEDING, WCB-250

This form is used to request a Provisional Order and/or an Expedited Proceeding. The employer, insurer, third-party administrator, employee, or attorney attaches this form to the front of the appropriate petition(s) and supporting documents and sends the complete packet to the Board’s Central Office in Augusta.

The Request for Expedited Proceeding is to be distributed as follows:


INSTRUCTIONS FOR COMPLETING REQUEST
FOR EXPEDITED PROCEEDING, WCB-250

Identifying Information

  1. Insurer File Number
    This box is provided for use by the insurer. If the insurer file number is known at the time of filing the Request for Expedited Proceeding, enter it here. The Board will record is for reference.
  2. Employer Name
    Enter the employer name as it was entered in box 10 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
  3. Employer Mailing Address and Phone Number
    Enter the address where the employer receives mail. Also enter the employer's phone number, including area code.
  4. Insurer Name
    Enter the name of the employer's workers' compensation insurer, self‑insured, or third‑party administrator if there is one.
  5. Insurer Mailing Address
    Enter the insurer, self‑insured, or third‑party administrator's mailing address.
  6. Social Security Number
    Enter the employee's social security number.
  7. WCB File Number
    If the preparer knows this number, enter it here. Doing so will speed up processing this form.
  8. Employee Last Name
    Enter the employee’s last name as entered in box 27 of the Employer’s First Report of Occupational Injury or Disease, WCB-1.
  9. First Name
    Enter the employee’s first name as entered in box 28 of the Employer’s First Report of Occupational Injury of Disease, WCB-1.
  10. M.I.
    Enter the employee’s middle initial as entered in box 29 of the Employer’s First Report of Occupational Injury or Disease, WCB-1.
  11. Address – Number and Street
    Enter the employee’s mailing address.
  12. City
    Enter the city of the employee’s mailing address.
  13. State
    Enter the state of the employee’s mailing address.
  14. Zip
    Enter the zip code of the employee’s mailing address.
  15. Home Phone Number
    Enter the employee’s home telephone number, including area code.
  16. Date of Injury
    Enter the date of injury. This date should be the same as box 42 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
  17. Description of Injury
    Enter a complete description of the injury.

Request for Provisional Order and Expedited Proceeding

  1. Check the appropriate box.

Request an Expedited Proceeding

  1. Sign and date the form
    Provide the name and mailing address of the preparer's legal representative (if any). Check the appropriate box to show who is represented.

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