Download - PA Form Book
SCRANTON 409 LACKAWANNA AVENUE SUITE 402 SCRANTON, PA 18503 JOSEPH M. CAPUTO [email protected] (570) 347-0600
PHILADELPHIA 450 SENTRY PARKWAY SUITE 200 BLUE BELL, PA 19422 JOHN F. HAYES [email protected] (610) 567-0700
MT. LAUREL, NJ 155 GAITHER DRIVE SUITE B MT. LAUREL, NJ 08054 GREGORY C. DICARLO [email protected] (856) 761-3800
WHEELING, WV 1144 MARKET STREET SUITE 300 WHEELING, WV 26003 NATHAN D. HUGHES [email protected] (304) 232-3600
CHARLESTON, WV 400 TRACY WAY SUITE 110 CHARLESTON, WV 25311 JEFFREY B. BRANNON [email protected] (304) 341-0500
WWW.C-WLAW.COM
New Jersey and West Virginia Offices
PITTSBURGH 650 WASHINGTON ROAD SUITE 700 PITTSBURGH, PA 15228 WALTER E. WERNER, III [email protected] (412) 563-2500
HARRISBURG 1011 MUMMA ROAD SUITE 201 LEMOYNE, PA 17043 DENNIS P. CULLEN [email protected] (717) 975-9600
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WARREN SMETHPORT
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MALVERN UPPER DARBY
PHILADELPHIA
HARRISBURG READING
HUNTINGDON
BUREAU OF WORKERS’ COMPENSATION FORMS
DENIAL Information for Notice of Workers’ Compensation Denial....……………………….... 1-2 LIBC-496 Notice of Workers’ Compensation Denial……………………………………………. 1-3 NCP Information for Notice of Compensation Payable…………………………………….. 1-6 LIBC-495 Notice of Compensation Payable……………………………………………………… 1-7 NTCP Information for Notice of Temporary Compensation Payable………………………… 1-10 LIBC-501 Notice of Temporary Compensation Payable…………………………………………. 1-11 LIBC-502 Notice Stopping Temporary Compensation Payable……………………………….. 1-13 ADJUSTER FORMS Information for Statement of Wages…………………………………………………... 1-15 Information for Calculation of Compensation Rate…………………………………... 1-17 LIBC-494C Statement of Wages (for injuries occurring on and after June 24, 1996………………. 1-19 Average Weekly Wage Schedule (2008 – 2012)……………………………………… 1-21 LIBC-344 Employer’s Report of Occupational Injury or Disease………………………………... 1-23 Information for Impairment Rating Evaluation………………………………………... 1-25 LIBC-766 Request for Designation of a Physician to Perform an Impairment Rating Evaluation........ 1-27 LIBC-765 Impairment Rating Evaluation Appointment………………………………………….. 1-29 LIBC-767 Impairment Rating Determination Face Sheet………………………………………… 1-31 LIBC-764 Notice of Change of Workers’ Compensation Disability Status………………………. 1-33 LIBC-500 Employer’s Workers’ Compensation Insurance Provider Information……………….. 1-35 LIBC-751 Notification of Suspension or Modification Pursuant to SS 413(C) & (D)………….... 1-37 LIBC-757 Notice of Ability to Return to Work…………………………………………………... 1-39 LIBC-761 Notice of Workers’ Compensation Benefit Offset…………………………………….. 1-41 LIBC-762 Notice of Suspension for Failure to Return Form LIBC-760…………………………. 1-43 LIBC-763 Notice of Reinstatement of Workers’ Compensation Benefits………………………... 1-45 Impairment Rating Evaluation Forms (LIBC-764, 765, 766, and 767) Reproduction Instructions……………………………………………………………... 1-47 Notice to All Insurance Carriers, TPAs, and Self Insured Employers………………… 1-49 LIBC-10 Authorization for Alternative Delivery of Compensation Payments………………….. 1-51 LIBC-392A Final Statement of Account of Compensation Paid…………………………………… 1-53 AGREEMENTS
LIBC-336 Agreement for Compensation for Disability or Permanent Injury……………………. 2-1 LIBC-337 Supplemental Agreement for Compensation for Disability or Permanent Injury…….. 2-3 LIBC-338 Agreement for Compensation for Death………………………………………………. 2-5 LIBC-339 Supplemental Agreement for Compensation for Death……………………………….. 2-7 LIBC-340 Agreement to Stop Weekly Workers’ Compensation Payments (Final Receipt)……... 2-9 LIBC-380 Third Party Settlement Agreement……………………………………………………. 2-11 LIBC-498 Commutation of Compensation……………………………………………………….. 2-13 LIBC-755 Compromise and Release Agreement by Stipulation Pursuant to Section 449 of the Workers’ Compensation Act…………………………………………………………... 2-15 LIBC-749 Death Claim Supplement to Compromise & Release Agreement…….......................... 2-19
EMPLOYEE REPORTING FORMS LIBC-750 Employee Report of Wages and Physical Condition………………………………….. 3-1 LIBC-756 Employee’s Report of Benefits………………………………………………………... 3-3 LIBC-760 Employee Verification of Employment, Self-Employment or Change in Physical Condition……………………………………………………………………. 3-5
PETITIONS
LIBC-362 Claim Petition for Workers’ Compensation…………………………………………… 4-1 LIBC-363 Fatal Claim Petition for Compensation by Dependents of Deceased Employees…….. 4-3 LIBC-376 Petition for Joinder of Additional Defendant………………………………………….. 4-5 LIBC-378 Petition to (Check any that apply)……………………………………………………... 4-7 LIBC-758 Notice to Claimant (to be attached to LIBC-378 Petition)……………………………. 4-9 LIBC-384 Fatal Claim Petition for Compensation by Dependents for Death Covered by the Pennsylvania Occupational Disease Act………………………………………………. 4-11 LIBC-386 Fatal Claim Petition for Compensation by Dependents for Death Resulting from Occupational Disease………………………………………………………………….. 4-13 LIBC-396 Occupational Disease Claim Petition………………………………………………….. 4-15 LIBC-499 Petition for Physical Examination or Expert Interview of Employee…………………. 4-17 LIBC-662 Application for Supersedeas Fund Reimbursement…………………………………… 4-19 LIBC-25/26 Appeal from Judge’s Findings of Fact and Conclusions of Law……………………… 4-21 LIBC-550 Claim Petition for Benefits from the Uninsured Employer and Uninsured Employer’s
Guaranty Fund ………………………………………………………………………… 4-23 LIBC-375 Claim Petition for Additional Compensation from the Subsequent Injury Fund……… 4-25
ANSWERS TO PETITIONS
LIBC-364B Defendant’s Answer to Claim Petition Under Pennsylvania Occupational Disease Act….. 5-1 LIBC-374 Defendant’s Answer to Claim Petition Under Pennsylvania Workers’ Compensation Act……………………………………………………………………... 5-3 LIBC-377 Answer to Petition to (Check all the apply)…………………………………………… 5-5 LIBC-524 Defendant’s Answer to Occupational Disease Claim Petition Section 301(i) Only…..…… 5-7
INFORMAL CONFERENCE FORMS
LIBC-753 Notice of Request for an Informal Conference………………………………………... 6-1 LIBC-754 Informal Conference Agreement Form………………………………………………... 6-3
PHYSICIAN’S AFFIDAVIT OF RECOVERY AND MEDICAL FORMS LIBC-9 Medical Report Form………………………………………………………………….. 7-1 LIBC-134 Dismemberment Chart………………………………………………………………... 7-3 LIBC-134F Dismemberment Chart………………………………………………………………... 7-5 LIBC-497 Physician’s Affidavit of Recovery…………………………………………………….. 7-7
UTILIZATION REVIEW AND FEE REVIEW FORMS
LIBC-507 Application for Fee Review Pursuant to Section 306(f.1)…………………………….. 8-1 Instructions for Utilization Review Request…………………………………………... 8-3 LIBC-601 Utilization Review Request……………………………………………………………. 8-5 LIBC-603 Petition for Review of Utilization Review Determination…………………………….. 8-7 LIBC-606 Request for Hearing to Contest Fee Review Determination……………….…………. 8-9
EMPLOYER/EMPLOYEE FORMS LIBC-510 Employer’s Application to Elect Domestic Employees to Come Within Provisions of The Workers’ Compensation Act: Section 321………………………………………. 9-1 Employer’s Light Duty Return to Work Form………………………………………… 9-3 LIBC-14 Instructions for Religious Exception Application……………………………………... 9-5 LIBC-14A Section 304.2 Application for Religion Exception of Specified Employees………….. 9-7 LIBC-14B Employee’s Affidavit and Waiver of Workers’ Compensation Benefits and Statement of Religious Sect………………………………………………………………………. 9-9
EMPLOYEE ACKNOWLEDGEMENT FORMS
Information for Employee Acknowledgement Forms………………………………… 10-1 Notice of Employee’s Rights & Duties………………………………………………... 10-3 Workers’ Compensation Information Form…………………………………………… 10-5
MISCELLANEOUS FORMS LIBC-480 Subpoena………………………………………………………………………………. 11-1 LIBC-551 Notice of Claim Against Uninsured Employer………………………………………... 11-3 Notes…………………………………………………………………………………… 11-5
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LEGAL DISCLAIMER: These instructions may change without notice based upon new case law, amendments to the Act, WC Rules, and/or BWC Regulations. Feel free to call one of the attorneys at Cipriani & Werner, P.C. using the phone numbers on the cover of this book to confirm that the law has not changed. Please note that the colored boxes on this form were added by C&W for instructional purposes only. Copies of forms acceptable to the Bureau should be obtained from the Bureau or a Bureau-approved vendor.
INFORMATION FOR NOTICE OF WORKERS’ COMPENSATION DENIAL (LIBC-496) DEADLINE:
21 days – Form must be filed within 21 days after the Employer is notified of work injury INJURY INFORMATION
When denying a claim, a broad denial is suggested. Use same words for all three questions. Such as the following:
Part of body injured: ANY AND ALL Nature of injury: ANY AND ALL Accident/injury description narrative: ANY AND ALL
NOTICE
In the middle of the form is a new section referred to as “Notice”, not to be confused with the “Date of Notice” at the top left of the form, which is the date you are issuing this form.
For “Notice”, the form allows you to use any of the following dates, which may be different; o the date that the Employer
received notice knew of alleged injury
or date of employee’s claimed disability
Remember whatever date you use make sure that it is within 21 days of the date you are executing the form.
WHICH BOX SHOULD I CHECK?
Box #1. We strongly recommend that you only select Box #1 in every case, since it is the only true denial, as all the other boxes are an admission of some sort.
If you “disregard” the last recommendation (LOL!) and want to select any of the Boxes #2-6, note
you are admitting that a work injury occurred, thus be as specific as possible. Such as the following: body parts affected: LEFT WRIST FRACTURE type of injury: LEFT WRIST FRACTURE description of injury: LEFT WRIST FRACTURE
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DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION
NOTICE OF WORKERS’ COMPENSATION DENIAL
DATE OF NOTICE
- - DD
E O EE OCIA EC IT N E O C ID N E DATE OF IN CAI C AI N E
- - - - DD
EMPLOYEE EMPLOYER
First name Name
Last name Address
Date of birth Address
Address City/Town State ZIP
Address County
City/Town State ZIP Telephone FEIN
County INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Telephone Name
AddressALLEGED INJURY INFORMATION Address
Part of body injured City/Town State ZIP
Nature of injury County
Accident/injury description narrative Telephone FEIN
Check if occupational disease Contact
NAIC code or Insurer code
Insurer/TPA claim #
NOTICE The employer/insurer has decided to deny you workers compensation bene ts ou have the ri ht to contest this denial by timely lin a petition with the bureau Petitions may be either electronically led in CAIS or sent to the orkers Compensation Of ce of Adjudication N Seventh St Suite arrisbur PA -
Do not use this form to accept a medical-only claim. This denial shall be sent to the employee or dependent and led with the bureau by electronic batch upload in CAIS by electronically attachin the document to a claim in CAIS or by mail no later than days after notice or knowled e to the employer of the employee s disability or death
Date the employer received notice or knew of alle ed injury or date of employee s claimed disability - -This date must be completed DD
The employer/insurer declines to pay workers compensation bene ts to claimant because
The employee did not suffer a work-related injury The de nition of injury also includes a ravation of a pre-e istin condition or disease contracted as a result of employment
The injury was not within the scope of employment
The employee was not employed by the defendant
The employee has not suffered a loss of wa es as a result of an already accepted injury
The employee did not ive notice of his/her injury or disease to the employer within days within the meanin ofSections - of the orkers Compensation Act
Other ood cause Please e plain fully in the space below
See Reverse Side For Employees’ Rights To Contest Denial
Claims representative’s name (typed/printed) Telephone
Claims representative’s si nature
LIBC-496 REV 09-13 (Page 1)
EMPLOYEES’ REIGHTS TO CONTEST DENIAL
You have the right to contest this denial of your claim for workers’ compensation benefits. Your petition will be heard by a workers’ compensation judge. You and your employer will have the opportunity to testify and provide medical evidence with respect to your claim. Both you and your employer will have the right to bring witnesses. You may retain an attorney to represent you in this proceeding although representation by an attorney is not required by law. Because of the legal complications that can arise in occupational disease and workers’ compensation cases, you may want to consider legal advice. If you do not know how to contact an attorney, please contact your local Bar Association or the Pennsylvania Bar Association at 800-692-7375 for guidance in obtaining an attorney.
The procedure for filing a petition is as follows:
1. To file a petition you may log onto the WCAIS system at www.dli.state.pa.us/WCAIS, or upon requent, a petition, Form LIBC-362, will be mailed to you. You or your attorney must complete and return the original petition to the Workers’ Compensation Office of Adjudication by electronically attaching the document to a claim in WCAIS or by mail to the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St., Suite 202, Harrisburg, PA 17102-1400.
2. A petition for an injury must be filed within three years of the date of injury. For occupational disease claims, disability or death must occur within 300 weeks from last exposure. A petition must be filed no later than three years from that date. Failure to file a petition within these rules may result in a loss of your claim.
3. You must give notice of your work-related injury or disease to your employer within 120 days of the date you knew (or should have known) that you were injured or had contracted a work-related disease.
4. When your petition is received by the Workers’ Compensation, Office of Adjudication, it will be assigned to a judge for hearing. You will be notified of your hearing date. All parties are requested to be fully prepared prior to the first hearing.
If you need petition forms or have questions, please contact the Workers’ Compensation, Office of Adjudication.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*496* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-496 REV 09-13 (Page 2)
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LEGAL DISCLAIMER: These instructions may change without notice based upon new case law, amendments to the Act, WC Rules, and/or BWC Regulations. Feel free to call one of the attorneys at Cipriani & Werner, P.C. using the phone numbers on the cover of this book to confirm that the law has not changed. Please note that the colored boxes on this form were added by C&W for instructional purposes only. Copies of forms acceptable to the Bureau should be obtained from the Bureau or a Bureau-approved vendor.
INFORMATION FOR NOTICE OF COMPENSATION PAYABLE (LIBC-495) DEADLINE:
21 days – Form must be filed within 21 days after the Employer is notified of work injury INJURY INFORMATION
When accepting liability for a claim, be specific. Use same words for all three questions. Such as the following:
Part of body injured: LEFT WRIST FRACTURE Nature of injury: LEFT WRIST FRACTURE Accident/injury description narrative: LEFT WRIST FRACTURE
MEDICAL ONLY BOX
You have the option to select the medical only box. If you do so, you do not need to fill out the wage information..
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DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION
NOTICE OF COMPENSATIONPAYABLE
DATE OF NOTICE
- -MM DD YYYY
EMPLOYEE SOCIAL SEC ITY N M E O C ID N M E DATE OF INJURY CAIS CLAIM NUM ER
- - - -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
INJURY INFORMATION
Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
NOTICE TO EMPLOYER This Notice should be clearly completed (preferably typed) and led with the ureau Filin with the ureau byelectronic batch upload in CAIS by electronically attachin the document to a claim in CAIS or by mail A copy must be sent to theinjured employee with the rst payment of compensationNOTICE TO EMPLOYEE If any uestions arise re ardin these payments contact the representative named at the bottom of this NoticeIf you cannot resolve a problem with the employer representative you may call the ureau at - -
Compensation is payable as follows: Check only if compensation for medical treatment (medical only, no loss of wages) will be paid subject to the orkers’ Compensation Act Compensation for medical treatment is payable from date of injury For compensation for medical treatment only you should not complete numbers throu h
eekly compensation rate ased on an avera e weekly wa e of
- - Payments be in on
MM DD
Date rst check mailed -MM DD
YYYY
(Compensation for loss of wa es is payable for rst days only if disability e tends or more days compensation for medical treatment is payable from the date of
injury )
- if the date e ceeds the -Rule check this bo and e plain on back of this form
YYYY
Payments will hereafter be made: eekly iweekly Other (Specify):
Any termination suspension or modi cation of these payments must be made by a reement nal receipt administrative or judicial determination or as otherwise provided in the orkers’ Compensation Act or Re ulations of the Department
(OVER)
LIBC-495 REV 09-13 (Page 1)
5. If injury involves loss under Section 306(c) (except for disfigurement of the head, face or neck) and employee has returned to work, complete the following information.
(a) Compensation is payable for weeks days for loss or loss of use of
(b) Employee returned to work without loss of income on - -MM DD YYYY
(c) Healing period payable for weeks days (Up to (b) above and subject to 7-day waiting period)
(d) Total (a) and (c) payable weeks days.
(e) Credit taken for disability benefits paid $ .
6. Remarks:
Claims representative’s name (typed/printed) Telephone
Claims representative’s signature
COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800.482.2383
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*495* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-495 REV 09-13 (Page 2)
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LEGAL DISCLAIMER: These instructions may change without notice based upon new case law, amendments to the Act, WC Rules, and/or BWC Regulations. Feel free to call one of the attorneys at Cipriani & Werner, P.C. using the phone numbers on the cover of this book to confirm that the law has not changed. Please note that the colored boxes on this form were added by C&W for instructional purposes only. Copies of forms acceptable to the Bureau should be obtained from the Bureau or a Bureau-approved vendor.
INFORMATION FOR NOTICE OF TEMPORARY COMPENSATION PAYABLE (LIBC-501) DEADLINES:
Filing: 21 days – Form must be filed within 21 days after the Employer is notified of work injury. Timing:
o The NTCP may be revoked within 90 days from the first day of disability; and
o Revocation must be circulated within 5 days of the last payment of wage-loss benefits.
For example: Date of Injury ----------- 01/01/2007
Notice of work injury -- 03/01/2007 Disability ---------------- 01/01/2007 Date form issued ------- 03/17/2007
90 days end on 4/1/2007, which is 90 days after the first date of the Claimant’s disability; note: This is not 90 days after the form was issued.
INJURY INFORMATION
When accepting liability for a claim, be specific. Use same words for all three questions. Such as the following:
Part of body injured: LEFT WRIST FRACTURE Nature of injury: LEFT WRIST FRACTURE Accident/injury description narrative: LEFT WRIST FRACTURE
MEDICAL ONLY BOX
You have the option to select the medical only box. If you do so, you do not need to fill out the wage information.
REVOKING NTCP FORM:
You must issue two forms to Revoke the NTCP, thus file both;
o 1. NOTICE STOPPING TEMPORARY COMPENSATION (LIBC-502) and
o 2.. NOTICE OF WORKERS’ COMPENSATION DENIAL (LIBC-496)
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DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION
NOTICE OF TEMPORARYCOMPENSATION PAYABLE
DATE OF NOTICE
- -
EMPLOYEE SOCIAL SECURITY NUM ER OR C ID NUM ER MM DD YYYY
DATE OF INJURY CAIS CLAIM NUM ER
- - - -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
INJURY INFORMATION
Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
MM DD YYYY EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
NOTICE TO EMPLOYER: In wa e loss claims a copy of the Notice is to be sent to the injured employee with the rst payment of temporary compensation. The original must be led with the Department of Labor Industry. Filing with the Department may be completed by electronic batch uploaded in CAIS by electronically attaching the document to a claim in CAIS or by mail. In wage loss claims the day period begins on the rst day of disability. The employer’s/insurer’s failure to le a notice as provided in Section 406. 1(d)(5) of the Act advising the employee that the employer is ceasing temporary compensation shall be deemed an admission of liability, and this notice shall be converted to a Notice of Compensation Payable. NOTICE TO EMPLOYEE: This Notice of temporary compensation payments is for a period of up to 90 days and is not an admission by your employer that it is responsible for your injury. If any questions arise, contact the representative at the bottom of this Notice. If you need further information, call the Bureau at 800-482-2383.
Compensation is payable as follows: Check only if compensation for medical treatment (medical only, no loss of wages) will be paid subject to the Workers’ Compensation Act. Compensation for medical treatment is payable from date of injury. If employer stops temporary compensation in accordance with the Act, employer will not pay for treatment received on or after the stoppage date. For compensation for medical treatment only, you should not complete numbers 1 or 3.
1. Weekly compensation rate $ .
Based on an average weekly wage of $ (A statement of wages must accompany this form.) . - -- -2. Ninety-day period begins on and ends on
MM DD YYYYMM DD YYYY
3. Payments will hereafter be made: Weekly Biweekly Other (Specify)
until payments cease or the ninety-day maximum period for temporary compensation expires.
Claims representative’s name Telephone
Claims representative’s signature (OVER)
LIBC-501 REV 09-13 (Page 1)
4. Remarks
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
employer information services
717.772.3702
claims information services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447
Hearing impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991
email [email protected]
*501* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-501 REV 09-13 (Page 2)
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department of labor & industry bureau of workers’ compensation
NOTICE STOPPINg TEMPORARY COMPENSATION
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY WCAIS CLAIM NUMBER
- - - -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
DATE OF THIS NOTICE - -MM DD YYYY
MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
NOTICE TO EMPLOYEE: This notice is being sent because payment of compensation, being paid pursuant to the Notice of
Temporary Compensation Payable, is being stopped as of .- -MM DD YYYY
The payment of temporary compensation does not mean that your employer assumed responsibility for your injury. Your employer and you retain all rights, defenses and obligations with regard to the claim. Further, the payment of temporary compensation may not be used to support a claim for benefits in a future proceeding.
WE HAVE ACCEPTED RESPONSIBILITY FOR YOUR CLAIM, AND ATTACHED IS A NOTICE OF COMPENSATION PAYABLE OR AN AGREEMENT FOR COMPENSATION; OR
WE HAVE DECIDED NOT TO ACCEPT LIABILITY, AND ATTACHED IS A NOTICE OF WORKERS’ COMPENSATION DENIAL. IF YOU BELIEVE YOU SUFFERED A WORK-RELATED INJURY, YOU WILL BE REQUIRED TO FILE A CLAIM PETITION WITH THE WORKERS' COMPENSATION OFFICE OF ADJUDICATION IN ORDER TO PROTECT YOUR FUTURE RIGHTS.
You have three years from the date of injury or discovery of your condition to file a Claim Petition for benefits. Since time limits can vary depending on the facts of your situation, you may wish to contact an attorney if you believe you may have a claim.
NOTICE TO INSURER: This form must be eitherAuthorized Agent for Insurer or TPA (if self-insured)
electronically filed in WCAIS or mailed to the Bureau Claims Representative’s signature of Workers’ Compensation, 1171 South Cameron
Street, Room 103, Harrisburg, PA 17104-2501 no later Claims Representative’s name (typed/printed) than five days after the last payment of temporary
Telephone compensation. A copy must be sent to the employee.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program *502*
LIBC-502 REV 09-13
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LEGAL DISCLAIMER: These instructions may change without notice based upon new case law, amendments to the Act, WC Rules, and/or BWC Regulations. Feel free to call one of the attorneys at Cipriani & Werner, P.C. using the phone numbers on the cover of this book to confirm that the law has not changed. Please note that the colored boxes on this form were added by C&W for instructional purposes only. Copies of forms acceptable to the Bureau should be obtained from the Bureau or a Bureau-approved vendor.
INFORMATION FOR STATEMENT OF WAGES (LIBC-494C) INFORMATION TO INCLUDE:
Wages, which include: Earnings Tips Gratuities weekly board/lodging commissions incentive vacation pay
TIME FRAME: The Average Weekly Wage (AWW) is computed as of the DATE OF THE INJURY (DOI), not the date of disability The time frame to calculate the AWW is the 12 months of wages prior to the DOI
FIXED WAGES:
Wages fixed by the month Multiply monthly wages by 12 and then divide by 52; Then add weekly board/lodging, gratuities/tips, bonuses, incentive, and vacation pay to arrive at
AWW.
Wages fixed by the year Divide yearly wages by 52 and then add weekly board/lodging, gratuities/tips, bonuses, incentive, and
vacation pay to arrive at AWW. NON-FIXED WAGES:
Question #1: Was Claimant employed for 4 consecutive 13 calendar week periods preceding the injury? If Yes, go to section A. If No, go to Question #2.
Section A:
Take the average of each 13 calendar week period by taking the gross wages earned during that period and dividing by 13;
Drop the period with the least earned income; Add averages of the 3 highest periods, then; Divide by 3 to arrive at AWW
Example:
Claimant’s pre-injury earnings Q1: $8,000
Q2: $9,000 Q3: $7,800 Q4: $9,300 Step 1: Throw out lowest 13 calendar week period, which is Q3 in above example.
Step 2: Average other 3 calendar week periods by dividing each by 13. Q1: $8,000 / 13 = $615.38
Q2: $9,000 / 13 = $692.31 Q4: $9,300 / 13 = $715.38
Step 3: Add averages ($615.38 + $692.31 + $715.38 = $2,023.07) Step 4: Divide total by 3 to arrive at average weekly wage ($2,023.07 / 3 = $674.36)
Question #2: Was Claimant employed for any consecutive 13 calendar week periods?
If Yes, go to section B. If No, go to Question #3.
LEGAL DISCLAIMER: These instructions may change without notice based upon new case law, amendments to the Act, WC Rules, and/or BWC Regulations. Feel free to call one of the attorneys at Cipriani & Werner, P.C. using the phone numbers on the cover of this book to confirm that the law has not changed. Please note that the colored boxes on this form were added by C&W for instructional purposes only. Copies of forms acceptable to the Bureau should be obtained from the Bureau or a Bureau-approved vendor.
Section B: Take the average of each 13 calendar week period by taking the gross wages earned during that
period and dividing by 13; Add averages of the periods worked, then; Divide by the number of complete periods to arrive at AWW.
Example:
Assume that Claimant had only worked for Q1 and Q2 prior to the DOI. Earnings:
Q1: $8,000 Q2: $9,000 Q3: 0.00 Q4: 0.00 Step 1: Add average weekly rate for each completed period.
(Q1 $615.38 + Q2 $692.31 = $1,307.69).
Step 2: Divide by the number of completed periods to arrive at AWW. ($1,307.69 / 2 = $653.85)
Question #3: Was Claimant employed for less than 13 calendar weeks prior to the injury?
If Yes, go to section C. If No, go back to Question #2.
Section C:
AWW shall be the hourly wage rate multiplied by the number of hours Claimant was expected to work.
Problem: What are the Expected Hours? Most Judges will simply calculate the total earnings and divide by the hours worked to arrive at the AWW, even if the Claimant did not work a complete 13 weeks prior to the DOI.
For examples:
Claimant is hired with no set hours per week. Claimant worked 4 weeks prior to the DOI.
Week #1 - 35 hours Week #2 - 42 hours Week #3 - 48 hours Week #4 - 40 hours
Claimant worked 165 hours (35 + 42 + 48 + 40), over 4 weeks, (165 / 4), thus his average hours are
41.25 per week. Note: If Claimant earned time and a half for hours over 40, he is sure to argue that his AWW should
include overtime earnings.
CONCURRENT EMPLOYMENT: Concurrent employment is when Claimant is working for more than one employer. Exclusions from concurrent employers:
volunteer firefighters income from self-employment
Calculation: Draft two (2) separate LIBC-494C STATEMENT OF WAGES forms Add AWW of each position job to determine the employee’s aggregate AWW.
Step 1- Complete each Statement of Wages as if Claimant was only employed by that Employer.
Step 2- On Primary Employer’s Statement of Wages (be sure to check off Primary or Concurrent Employer), use comment space in #8 to add the Primary and Concurrent Employer’s AWW together.
Step 3- Calculate Claimant’s Compensation Rate based on the aggregate AWW.
Example: $600.00 AWW with Primary Employer + $350.00 AWW with Concurrent Employer $950.00 aggregate AWW
1-16
1-17
LEGAL DISCLAIMER: These instructions may change without notice based upon new case law, amendments to the Act, WC Rules, and/or BWC Regulations. Feel free to call one of the attorneys at Cipriani & Werner, P.C. using the phone numbers on the cover of this book to confirm that the law has not changed. Please note that the colored boxes on this form were added by C&W for instructional purposes only. Copies of forms acceptable to the Bureau should be obtained from the Bureau or a Bureau-approved vendor.
INFORMATION FOR CALCULATION OF THE COMPENSATION RATE WEEKLY COMPENSATION RATE:
The Compensation Rate is based upon the Pennsylvania WORKERS' COMPENSATION RATE SCHEDULES Compare AWW to the SCHEDULE (page 1-21) Generally, Claimant’s wage-loss benefits are equal to two-thirds of their weekly wage for a work-related injury.
However, there are minimum and maximum Compensation Rates, which are based on the Department of Labor
and Industry's calculation of the statewide AWW.
CALCULATING THE WEEKLY COMPENSATION RATE:
Generally- Weekly Compensation Rate is calculated by dividing the Claimant’s AWW by 2/3. For example:
DOI – 08/17/2013 AWW of $880.36
$880.36 AWW x 66.666%
$586.91 Weekly Compensation Rate
CR $586.91, which is 66 2/3% of the AWW, based upon RATE SCHEDULE below. 2013
_______________ Maximum: $917.00 01/01/13 _______________ $1,375.50
66 2/3% $687.76 _______________ $687.75
$458.50 $509.44 _______________ $509.43
or 90% Less _______________
TEMPORARY PARTIAL DISABILITY:
How to Calculate TPD Benefits? 2/3 of the difference between Claimant’s AWW and present earnings.
Example: $880.36 AWW
- $500.00 Present earnings $380.36 x 2/3 $253.57 TPD rate
1-18
1-19
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION
STATEMENT OF WAGES(FOR INJURIES OCCURRING
ON OR AFTER JUNE 24, 1996)
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County Telephone
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
CONCURRENT EMPLOYMENT ONLY Check if Primary employer OR
Concurrent employer
INSTRUCTIONS
The Statement of Wages must be clearly completed in accordance with the Pennsylvania Workers’ Compensation Act and uploaded in accordance with the provisions of the EDI Implementation guide when submitting certain EDI transactions. A copy must be sent to the injured employee.
The average weekly wage is used to determine the amount of weekly compensation wage-loss bene ts payable under the Pennsylavania Workers’ Compensation Act. A chart is available from the Bureau of Workers’ Compensation to aid in determining the weekly compensation rate, online at www.dli.state.pa.us
CONCURRENT EMPLOYMENT
If the employee had more than one employer at the time of injury, a separate Statement of Wages form must be completed for each employer. Submit these forms together. Using #8 on the Primary Employer’s form only (employer with whom the injury occurred): show the addition of the average weekly wages from all employers, show the combined average weekly wage to the right of the equal sign and show the appropriate workers’ compensation rate. Check the Primary employer box for the Primary employer and the Concurrent employer box for all other employers.
LIBC-494C REV 09-13 (Page 1)
Computation: Compute the appropriate items below for the employee to determine the average weekly wage. Weekly Annual
Weekly Federal Bonus, Board/ Reported Incentive or Average
Wage Lodging Gratuities Vacation Weekly Wage
1. If wages are xed by the week: + + + = $
2. If wages are xed by the month: x 12 ÷ 52 + + + = $
3. If wages are xed by the year: ÷ 52 + + + = $
4. If paid in another manner, then complete the following for each of the last four consecutive periods of 13 calendar weeks preceding the injury.
From Through
1st Period
2nd Period
3rd Period
4th Period
Wages
+
+
+
+
Federal Reported Board/Lodging Gratuities
+ 13
+ 13
+ 13
+ 13
(Sum of three highest periods)
Annual bonus, incentive and vacation $ ÷ 52 = $ (Weekly bonus, etc)
Sum of the highest three period weekly averages = $ ÷ 3 + $ (Weekly bonus, etc)
5. If the employee has not been employed by the employer for at least three consecutive periods of 13 calendar weeks in the 52 weeks preceding the injury, use #4 above and put in the wages for any completed periods(s) of 13 weeks immediately preceding the injury and average the total
amounts ..............................................................................................................................
6. If the employee worked less than a complete period of 13 calendar weeks and does not have xed weekly wages: hourly wage rate $ x the number of hours the employee was expected to work per week under the terms of employment =$ + weekly board/lodging of $ + weekly federal reported gratuities $ + (annual bonus, incentive or vacation pay ÷ 52) $ .....................................................................................
. For seasonal occupations, the average weekly wage is one- ftieth of the total wages earned from all occupations during the 12 months immediately preceding the injury. Twelve months
prior earnings $ ÷ 50 = $ + weekly board/lodging $ + weekly federal reported gratuities $ ................................................................
8. If the calculation in #7, or any other calculation above, does not fairly ascertain the earnings of the employee, the period of calculation is extended to give a fair calculation of their average weekly wage. Show this calculation here OR use the space below to show calculations for concurrent employment.
Period Weekly Wage
= $
= $
= $
= $
= $ Average Weekly Wage
= $
= $
= $
= $
= $
COMPENSATION PAYABLE PER WEEK: = $
Employer/Defendant Representative’s signature Employer/Defendant Representative’s name (typed/printed)
Telephone
Any individual ling misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991
*494C*Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/ProgramLIBC-494C REV 09-13 (Page 2)
1-20
1-21
Ave
rag
e W
eekl
y W
age
Sch
edu
le
20
10
2
01
1
20
12
2
01
3
20
14
Max
imum
: $8
45.0
0
01
/0
1/
10
$1,2
67.5
0
66 2
/3%
$6
33.7
6
$633
.75
$422
.50
$4
69.4
4
$469
.43
or
90
%
Less
Max
imum
: $8
58.0
0
01
/0
1/
11
$1,2
78.0
0
66 2
/3%
$6
43.5
1
$643
.50
$429
.00
$4
76.6
7
$476
.66
or
90
%
Less
Max
imum
: $8
88.0
0
01
/0
1/
12
$1,3
32.0
0
66 2
/3%
$6
66.0
1
$666
.00
$444
.00
$4
93.3
3
$493
.32
or
90
%
Less
Max
imum
: $9
17.0
0 0
1/
01
/1
3
$1,3
75.5
0
66 2
/3%
$6
87.7
6
$687
.75
$458
.50
$509
.44
$509
.43
or
90%
Le
ss
Max
imum
: $
01
/0
1/
14
$
66 2
/3%
$ $
$ $ $ or
90
%
Less
1-22
(OVER)
EMPLOYEE FIRST NAME
EMPLOYEE LAST NAME
STREET ADDRESS
CITY STATE ZIP CODE
COUNTY PHONE NUMBER
EMPLOYEE: NUMBER OF DEPENDENTS DATE OF BIRTH
MALE MARRIED
FEMALE SINGLE
OCCUPATION OR JOB TITLE
NCCI CLASS CODE (IF KNOWN) EMPLOYMENT STATUS FT = Full-time SL = SeasonalPT = Part-time VO = Volunteer
ZZ = Other
EMPLOYER
STREET ADDRESS
CITY STATE ZIP CODE
SIC CODE EMPLOYER FEIN PHONE NUMBER
COUNTY NAICS CODE
FULL PAY FOR DAY OF INJURY? TIME EMPLOYEE BEGAN WORK TIME OF OCCURRENCE
YES
NO
LAST DAY WORKED DATE DISABILITY BEGAN
DATE EMPLOYER NOTIFIED DATE RETURNED TO WORK DATE OF HIRE
CONTACT FIRST NAME CONTACT PHONE NUMBER
CONTACT LAST NAME
NOTICE: Report should be clearly completed, (preferably typed)and original mailed to the Bureau at the address in the upper leftcorner and a copy to employee and insurer.
LIBC-344 REV 1-01
COMMONWEALTH OF PENNSYLVANIADEPARTMENT OF LABOR AND INDUSTRYBUREAU OF WORKERS’ COMPENSATION
1171 S. CAMERON STREET, ROOM 103HARRISBURG, PA 17104-2501
(TOLL FREE) 800-482-2383TTY (TOLL FREE) 800-362-4228
EMPLOYER’S REPORTOF OCCUPATIONALINJURY OR DISEASE
EMPLOYEE SOCIAL SECURITY NUMBER
DATE OF INJURY
- -
- -
-
- -MONTH DAY YEAR
- - -
: :
- - - -
- -
MONTH DAY YEAR MONTH DAY YEAR
- - - -MONTH DAY YEAR MONTH DAY YEAR
- -MONTH DAY YEAR
- -
MONTH DAY YEAR
AM
PM
AM
PM
-
1-23
LIBC 344
TYPE OF INJURY CODE PART OF BODY AFFECTED CODE CAUSE OF INJURY CODE (ENTER CODES, IF KNOWN)
TYPE OF INJURY OR ILLNESS
PARTS OF BODY AFFECTED
CAUSE OF INJURY
DID INJURY OR ILLNESS OCCUR IF OUT OF STATE, SPECIFY WERE SAFEGUARDS OR SAFETY WERE SAFEGUARDS OR SAFETYON EMPLOYER’S PREMISES? STATE OF INJURY EQUIPMENT PROVIDED? EQUIPMENT USED?
YES YES YES
NO NO NO
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES DIRECTLY RESPONSIBLE.
IF FATAL, GIVE DATE OF DEATH
MONTH DAY YEAR
PHYSICIAN/HEALTH CARE PROVIDER
FIRST NAME: LAST NAME:
STREET
CITY STATE ZIP
HOSPITAL NAME:
STREET
CITY STATE ZIP
POLICY/SELF INSURED NUMBER:
WITNESS FIRST NAME WITNESS PHONE NUMBER
WITNESS LAST NAME
PERSON COMPLETING THIS FORM: INSURANCE CARRIER OR THIRD PARTY ADMINISTRATOR (IF SELF-INSURED)
NAME:
TITLE:
PHONE:STATE ZIP
FEIN:
DATE PREPARED
MONTH DAY YEAR
Any individual filing misleading or incomplete information knowingly and with intent todefraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Actand may also be subject to criminal and civil penalties through Pennsylvania Act 165.
INITIAL TREATMENT:
NO MEDICAL TREATMENT
MINOR BY EMPLOYEE
CLINIC / HOSPITAL
PANEL PHYSICIAN
EMPLOYEE PHYSICIAN
EMERGENCY CARE
HOSPITALIZED MORE THAN 24 HOURS
POLICY PERIOD FROM:
MONTH DAY YEAR
POLICY PERIOD TO:
MONTH DAY YEAR
- -
- -
- -
- -
- -
NAME:
STREET
CITY
BUREAU CODE:
1-24
1-25
LEGAL DISCLAIMER: These instructions may change without notice based upon new case law, amendments to the Act, WC Rules, and/or BWC Regulations. Feel free to call one of the attorneys at Cipriani & Werner, P.C. using the phone numbers on the cover of this book to confirm that the law has not changed. Please note that the colored boxes on this form were added by C&W for instructional purposes only. Copies of forms acceptable to the Bureau should be obtained from the Bureau or a Bureau-approved vendor.
INFORMATION FOR IMPAIRMENT RATING EVALUATION STARTING LINE:
104 weeks: Claimant must first receive 104 weeks of Temporary Total Disability (TTD) benefits before you can compel an Impairment Rating Evaluation (IRE).
60-DAY WINDOW QUESTION:
Are you within 60 days (“60-day window”) of the Claimant’s receipt of 104 weeks of TTD? If yes, go to Checklist A. If No, go to Checklist B.
CHECKLIST A: During the 60-day window you must complete all of the following actions, numbered 1 through 4;
1. File LIBC-766 form titled REQUEST FOR DESIGNATION OF A PHYSICIAN TO PERFORM AN IMPAIRMENT RATING EVALUATION. [The parties may agree on an IRE Physician; if so, go to #3 below.];
2. Wait for the Bureau of Workers’ Compensation (BWC) to designate an IRE physician;
3. Schedule IRE and serve upon the Claimant LIBC- 765 form titled IMPAIRMENT RATING EVALUATION APPOINTMENT;
and 4. Have the IRE performed;
IRE DETERMINATION:
Wait for IRE physician to issue LIBC-767 form titled IMPAIRMENT RATING DETERMINATION FACE SHEET. If IRE determination is less than 50%, then;
File LIBC-764 form titled NOTICE OF CHANGE OF WORKERS’ COMPENSATION DISABILITY STATUS.
___________________________________________
CHECKLIST B: If you do not complete all of the actions above, numbered 1 through 4, during the 60-day window you still may obtain an IRE by completing all of the following steps;
1. File LIBC-766 form titled REQUEST FOR DESIGNATION OF A PHYSICIAN TO PERFORM AN
IMPAIRMENT RATING EVALUATION. [The parties may agree on an IRE Physician; if so, go to #3 below.];
2. Wait for the Bureau of Workers’ Compensation (BWC) to designate an IRE physician;
3. Schedule IRE and serve upon the Claimant LIBC- 765 form titled IMPAIRMENT RATING EVALUATION APPOINTMENT;
and 4. Have the IRE performed.
IRE DETERMINATION:
Wait for IRE physician to issue LIBC-767 form titled IMPAIRMENT RATING DETERMINATION FACE SHEET. If IRE determination is less than 50%, then;
You must refer the file to an attorney to file a Modification Petition to request a Workers’ Compensation Judge to cap the TTD benefits at a maximum of an additional 500 weeks effective as of the date of the IRE evaluation.
1-26
1-27
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION
REQUEST FOR DESIGNATION OF A PHYSICIAN TO PERFORM AN
IMPAIRMENT RATING EVALUATION
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
ATTORNEY FOR EMPLOYEE (if known)
Name
Firm name
Address
Address
City/Town State ZIP
Telephone PA Attorney ID number
ATTORNEY FOR INSURER/EMPLOYER (if known)
Name
Firm name
Address
Address
City/Town State ZIP
Telephone PA Attorney ID number
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
CLAIMS REPRESENTATIVE
Name
Address
Address
City/Town
Telephone
State
FEIN
ZIP
SEE IMPORTANT INFORMATION ON THE REVERSE
LIBC-766 REV 09-13 (Page 1)
Description of compensable injury:
This is an Act 46 (firefighter cancer) claim
The referenced Insurer/Employer requests the Bureau of Workers’ Compensation to select a physican for an Impairment Evaluation to be conducted with Section 306(a.2) of the Workers’ Compensation Act.
Copies of this request have been served on all parties.
Date of this notice
- -Claims Representative’s signature
MM DD YYYY
Claims Representative’s name (typed/printed)
Telephone
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*766* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-766 REV 09-13 (Page 2)
1-28
1-29
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION
IMPAIRMENT RATING EVALUATION APPOINTMENT
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
ATTORNEY FOR EMPLOYEE (if known)
Name
Firm name
Address
Address
City/Town State ZIP
Telephone PA Attorney ID number
ATTORNEY FOR INSURER/EMPLOYER (if known)
Name
Firm name
Address
Address
City/Town State ZIP
Telephone PA Attorney ID number
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
CLAIMS REPRESENTATIVE
Name
Address
Address
City/Town
Telephone
State
FEIN
ZIP
SEE IMPORTANT INFORMATION ON THE REVERSE
LIBC-765 REV 09-13 (Page 1)
Important Notice: Section 306(a.2) of the Pennsylvania Workers’ Compensation Act provides that an insurer (employer) may request a workers’ compensation claimant, on total disability status, to attend a medical examination to determine the degree of their impairment due to the compensable injury. This examination should occur after the expiration of 104 weeks of total disability. The purpose of the examination is to determine the degree of impairment using the American Medical Association “Guides to the Evaluation of Permanent Impairment.” If this evaluation results in an impairment rating of less than 50 percent, your benefits status will change to “partial disability” which has a 500 week duration limit. The amount of wage loss compensation checks you are receiving is not affected by this change in status. If this evaluation is requested and scheduled within 60 days of the end of the 104 week period and results in a change to partial disability status, the effective date for that change is at the end of the 104 weeks. If the evaluation is initially scheduled more than 60 days after the end of the 104 weeks, any resulting change in status occurs on the date of the medical evaluation or as determined by the evaluating physician.
Prior to your receiving this form, you or your attorney (if appropriate) may have been contacted regarding your agreement to the selection of an impairment rating physician. In the alternative, the Department of Labor & Industry may have been requested to assign an impairment rating physician.
If you fail to attend the impairment rating evaluation, your workers’ compensation benefits may be suspended (stopped) through the decision of a Workers’ Compensation Judge.
You have received 104 weeks of total disability benefits as of - -MM DD YYYY
You have been scheduled for a medical examination with Dr. NAME
who is located at:
- -Please report to this office at AM PM on TIME
MM DD YYYY
The doctor has been selected: through mutual agreement of parties
by the Department of Labor & Industry, Bureau of Workers’ Compensation
Please be prompt in arriving for this examination. You will be advised by an official notice of the results of the evaluation.
A copy of this impairment rating evaluation appointment is being provided to the employee and the employee’s attorney (if known).
- -Date filed
MM DD YYYY
Claims representative’s signature
Claims representative’s name (typed/printed)
Telephone
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991
Email [email protected]
*765* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-765 REV 09-13 (Page 2)
1-30
1-31
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION
LIBC-767 REV 09-13 (Page 1)
IMPAIRMENT RATING DETERMINATION FACE SHEET
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
ATTORNEY FOR EMPLOYEE (if known)
Name
Firm name
Address
Address
City/Town State ZIP
Telephone PA Attorney ID number
ATTORNEY FOR INSURER/EMPLOYER (if known)
Name
Firm name
Address
Address
City/Town State ZIP
Telephone PA Attorney ID number
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
CLAIM REPRESENTATIVE
Name
Address
Address
City/Town State ZIP
Telephone FEIN
SEE IMPORTANT INFORMATION ON THE REVERSE
I examined the referenced employee, , with regard to establishing an impairment rating determination to define the degree of impairment due to the compensable injury, if any, in accordance with the provision of Section 306(a.2) of the Pennsylvania Workers’ Compensation Act.
Attached is the Report of Medical Evaluation prepared as utilized by the most recent edition of the American Medical Association Guides to the Evaluation of Permanent Impairment.
The original of this face sheet and report is being provided to the Bureau of Workers’ Compensation, Healthcare Services Review Division, 1171 S. Cameron Street, Harrisburg, PA 17104-2501, with copies to the employee, the employee’s attorney (if known) and the insurer within 30 days of the date of the impairment evaluation.
Name of patient:
Social Security number: XXX-XX-
Date of birth:
Date of this examination:
Percentage of impairment rating: %
My charge of $ examination.
will be billed to the Insurer or Third Party Administrator (if self-insured) for conducting this
I attest that I am a physician in the Commonwealth of Pennsylvania and certified by an American Board of Medical Specialities approved board or its osteopathic equivalent, and that I have an active clinical practice of at least twenty (20) hours per week.
Physician
Name
Address
Address
City/Town State ZIP
Telephone
Federal Tax ID number
MC Provider #NPI#
Specialty
Contact
Date of this notice
Provider or Representative’s signature - -MM DD YYYY
Provider or Representative’s name (typed/printed)
Telephone
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*767* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-767 REV 09-13 (Page 2)
1-32
1-33
notice of change of department of labor & industry workers’ compensationbureau of workers’ compensation
disability status
DATE OF NOTICE
- -MM DD YYYY
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
employee
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
attorney for employee (if known)
Name
Firm name
Address
Address
City/Town State ZIP
Telephone PA Attorney ID number
attorney for insurer/employer (if known)
Name
Firm name
Address
Address
City/Town State ZIP
Telephone PA Attorney ID number
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
employer
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
insurer or third party administrator (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
claims representatiVe
Name
Address
Address
City/Town
Telephone
State
FEIN
ZIP
see important information on the reVerse This notice should be clearly completed (preferably typed) and original mailed to the bureau at the address on the back of this sheet. A copy must be sent to the employee and the employee’s counsel (if known).
(OVER)
LIBC-764 REV 09-13 (Page 1)
As a result of an impairment rating evaluation (examination), your disability status has changed.
A change in disability status does not affect the amount of money you receive in your workers’ compensation check. Partial disability status does, however, have a maximum period of 500 weeks of benefits.
The specifics of this change are listed as follows:
Claimant name:
Social Security number: - -
Date of injury:
Date you reached a total of 104 weeks of total disability:
- -MM DD YYYY
- -MM DD YYYY
Date initially established for the examination: - -MM DD YYYY
- -Actual date of the rating examination: MM DD YYYY
Impairment examining physician:
Impairment rating percentage: percent
This rating evaluation was conducted in accordance with Section 306(a.2) of the Pennsylvania Workers’ Compensation Act.
The above referenced Impairment Rating percentage has been used by your insurance carrier/employer to change your workers’ compensation status from total disability to partial disability status.
- -MM DD YYYY
The effective date of this status change is . (This effective date will be recorded on your
claim record 60 days following the date of this notice)
-or-
The result of this rating evaluation is that no change is occurring in your disability status.
Commonwealth of Pennsylvania Department of Labor & Industry Bureau of Workers’ Compensation 1171 S. Cameron Street, Room 103 Harrisburg, PA 17104-2501
insurer/employer representatiVe
First name
Last name
Signature
Address
Address
City/Town State ZIP
Telephone
Bureau Code
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S.
§1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
employer information claims information services hearing impaired email services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*764* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-764 REV 09-13 (Page 2)
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REMEMBER:It is Important to Tell YourEmployer about Your Injury
The name, address and telephone number of your employer’s workers’ compensation insurance company, third-party administrator (TPA), or person handling workers’ compensation claims for your company, are shown below.
Employer Name: Date Posted:
IF INSURED: IF SOMEONE OTHER THAN INSURER IS (Complete all applicable spaces) HANDLING CLAIMS: (Complete all applicable spaces)
Name of Insurance Company: Name of TPA (Claims administrator):
Address: Address:
Telephone Number: Telephone Number:
Insurer’s Bureau Code:
IF SELF-INSURED: IF SOMEONE OTHER THAN SELF-INSURER (Complete all applicable spaces) IS HANDLING CLAIMS: (Complete all applicable spaces)
Name of person handling claims at Name of TPA (Claims administrator):
the self-insured:
Address: Address:
Telephone Number: Telephone Number:
Self-Insured Bureau Code:
Department of Labor & Industry | Bureau of Workers’ Compensation | 1171 S. Cameron Street, Room 103 | Harrisburg, PA 17104-2501 717.772.0621 | www.dli.state.pa.us
Auxiliary aids and services are available upon request to individuals with disabilities.Equal Opportunity Employer/Program
LIBC-500 REV 5-09
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1-37
department of labor & industry bureau of workers’ compensation
NOTIfICATION Of SUSPENSION OR MODIfICATION PURSUANT
TO §§ 413 (c) & (d)
- -DATE OF NOTIFICATION
MM DD YYYY
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY WCAIS CLAIM NUMBER
- - - -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
INSTRUCTIONS
This form must be completed, notarized and either uploaded in WCAIS or mailed to the Bureau of Workers’ Compensation (BWC), 1171 South Cameron Street, Room 103, Harrisburg, PA 17104-2501. This form must be mailed to the employee and filed with BWC within seven days of a suspension or modification of benefits under the provisions of the Workers’ Compensation Act.
MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
You are notified that because you returned to work on , your weekly disability benefits for this - -injury have been: MM DD YYYY
- -Suspended effective because you have returned to work at earnings equal to or greater than your MM DD YYYY
time-of-injury earnings of $ . OR
Modified to the rate of $ per week, effective because you returned - -to work at earnings less than your time-of-injury earnings. MM DD YYYY
INSURER’S AffIDAVIT I attest or affirm that the statements contained herein are true and correct to the best of my knowledge, information and belief.
affix seal here
Claims representative’s signature SUBSCRIBED AND SWORN TO (OR AFFIRMED) BEFORE ME THIS
Claims representative’s name (typed/printed) DAY OF ,
Phone number Signature of notary
NOTE TO EMPLOYEE: If you do not agree with this action and wish to challenge it, please read the instructions under EMPLOYEE CHALLENGE on the back of this form.
LIBC-751 REV 09-13 (Page 1)
Weekly wages must be computed in accordance with the Pennsylvania Workers’ Compensation Act.
CALCULATION for partial compensation rate (to be completed for modification). The employee’s new partial compensation rate is based on the claimant’s present weekly earning and is calculated as follows:
Calculation: Average weekly wage at time of injury
minus: Present weekly earnings
Subtotal
x 2/3 = New partial compensation rate (Subject to the maximum benefit)
EMPLOYEE CHALLENGE:
If you do not agree with this action, you must challenge it within (20) days of the date you receive this notice. Challenge it online at www.WCAIS.pa.gov. Choose file petition action, choose challenge and the claim number you want to challenge. In the alternative, you may challenge by checking the box below, signing this form and mailing it to the Pennsylvania Department of Labor & Industry, Workers’ Compensation Office of Adjudication (WCOA), 1010 N 7th Street, Suite 201, Harrisburg, PA 17102-1400. This material must be filed with the (WCOA) within (20) days from the date you received it.
If you do not challenge this action within (20) days of the date you receive this notice, you will be deemed to have admitted that you agree with the action taken on this form. In that case, this notice will have the same binding effect as a fully executed Supplemental Agreement for the suspension or modification of benefits.
I do not agree with the action taken by my employer. I request a special supersedeas hearing (a hearing on whether my workers’ compensation benefits can be reduced or stopped) before a Workers’ Compensation Judge. A hearing is requested to be conducted in accordance with Sections 413 (c) & (d) of the Pennsylvania Workers’ Compensation Act. (if the employee has legal counsel, complete below.)
Employee’s signature Attorney’s name
AddressPA attorney ID#
AddressName of firm
City/Town State ZIPAddress
County Address
Telephone City/Town State ZIP (Employee to complete if different from information provided by employer)
Telephone
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*751* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-751 REV 09-13 (Page 2)
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EMPLOYER
department of labor & industry bureau of workers’ compensation
NOTIcE Of AbILITY TO RETURN TO wORk
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
DATE OF NOTICE
- -MM DD YYYY
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
Section 306(b)(3) of the Pennsylvania Workers’ Compensation Act requires insurers to notify the employee when they receive medical evidence indicating the ability to return to work in some capacity.
Receipt of medical evidence indicates your present physical condition or change of condition is:
Attached are all documents supporting these allegations.
YOU SHOULD ALSO kNOw You have an obligation to look for available employment. Proof of available employment may jeopardize your right to receive ongoing benefits. You have the right to consult with an attorney in order to obtain evidence to challenge the insurer’s contributions.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S.
§1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Auxiliary aids and services are available upon request to individuals with disabilities.
Employer Information claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*757*Equal Opportunity Employer/Program
LIBC-757 REV 09-13
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NOTICE OF SUSPENSIONCOMMONWEALTH OF PENNSYLVANIAFOR FAILURE TO RETURNDEPARTMENT OF LABOR AND INDUSTRY
BUREAU OF WORKERS' COMPENSATION FORM LIBC-7601171 S. CAMERON STREET, ROOM 103(EMPLOYEE VERIFICATION OFHARRISBURG, PA 17104-2501 DDMM YYYY
EMPLOYMENT, SELF-EMPLOYMENT(TOLL FREE) 800-482-2383(IF KNOWN)OR CHANGE IN PHYSICAL CONDITION)
EmployerEmployee
Zip CodeStateState Zip Code
Insurer or Third Party Administrator (if self-insured)
State Zip Code
YYYYMM DD
Attorney for Insurer/Employer (if known)Attorney for Employee (if known)
Zip Code Zip CodeStateState
Claim RepresentativeLast Name
Signature
A COPY OF THIS FORM AND ATTACHMENTS ARE TO BE PROVIDED TO THE EMPLOYEE, THE EMPLOYEE'SATTORNEY (IF KNOWN), AND THE ORIGINAL MUST BE MAILED TO PENNSYLVANIA DEPARTMENT OF LABORAND INDUSTRY, BUREAU OF WORKERS' COMPENSATION, AT THE ADDRESS SHOWN ABOVE.
(OVER)LIBC-762 REV 12-97
First Name
Street 1
Telephone
Street 2
City/Town
County
Last Name Name
Street 1
Street 2
City/Town
County
Telephone FEIN
Name
Street 1
Street 2
FEIN
City/Town
Telephone
County
Claim Number
Bureau Code
Name
Firm Name
Street 1
Street 2
City/Town
PA Attorney ID NumberTelephone
Name
Firm Name
Street 1
Street 2
City/Town
Telephone PA Attorney ID Number
First Name
Telephone
Date of Injury:
Social Security Number:
PA BWC Claim Number:
DATE OF THIS NOTICE:
762 1297-1
American LegalNet, Inc.www.USCourtForms.com
LIBC-762
dueYYYYDDMM
to your failure to return theform (LIBC-760) which was mailed to you on . This form was due for return to the sender within 30
MM DD YYYY
calendar days of its receipt. Your failure to return the completed form within this time period entitles your insurer/employer
to suspend your workers' compensation benefits under Section 311.1(g) of the Pennsylvania Workers' Compensation
Your workers' compensation benefits will immediately begin again upon your insurer/employer's receipt of the verificationform, but you provisions of Section 311.1(d) may subject you to prosecution under the provisions of Article XI of the Pennsylvania Workers'Compensation Act relating to fraud.
If you did return the completed LIBC-760 within the prescribed time period, contact the forms sender (insurer/employer)immediately to clarify this matter.
Attached is another copy of the Employee Verification form to assure that you have the opportunity to complete and return itpromptly to stop this suspension action.
You may challenge the suspension on legal grounds by filing a Petition for Reinstatement with the Pennsylvania Bureau ofWorkers' Compensation at the address listed on the front. Petitions can be obtained by calling the Bureau at 1-800-482-2383.
Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania
Attachment: Employee Verification Form LIBC-760
Employee Verification of Employment, Self-Employment or Change in Physical Condition
receive reinstated benefits for the period of this suspension. In addition, failure to comply with thewill not
Act 165 of 1994.
Act.
You are hereby notified that your workers' compensation benefits have been suspended as of
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changes of employment, self-employment or change in physical condition.
NOTICE OFCOMMONWEALTH OF PENNSYLVANIAREINSTATEMENT OFDEPARTMENT OF LABOR AND INDUSTRY
BUREAU OF WORKERS' COMPENSATION WORKERS'1171 S. CAMERON STREET, ROOM 103HARRISBURG, PA 17104-2501 DD YYYYMMCOMPENSATION(TOLL FREE) 800-482-2383
BENEFITS (IF KNOWN)
EmployerEmployee
State Zip CodeZip CodeState
Insurer or Third Party Administrator (if self-insured)
Zip CodeState
YYYYMM DD
Attorney for Insurer/Employer (if known)Attorney for Employee (if known)
Zip CodeState
Claim RepresentativeA COPY OF THIS FORM IS TO BE PROVIDED TO THE EMPLOYEE, THE EMPLOYEE'S ATTORNEY (IF KNOWN), AND THE ORIGINAL MUST BE MAILED TO BUREAU OF WORKERS' COMPENSATION AT THE ADDRESS SHOWN ABOVE.
Last Name
Signature
, the dateMM YYYYDD
yourreceived, which indicated
, the dateDD YYYYMM
your completed LIBC-760 form was received. A benefit offset will occur as indicated on the attachedWorkers' Compensation Benefit Offset
Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of thePennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994.
LIBC-763 REV 12-97
Employee Verification of Employment, Self-Employment or Change in Physical Condition (LIBC-760) was- OR -
Notice of(LIBC-761).
NO
Social Security Number:
Date of Injury:
PA BWC Claim Number:
First Name Last Name
Street 1
City/Town
County Telephone
Street 2
Name
City/Town
County
Telephone
Street 1
Street 2
FEIN
Name
Street 2
City/Town
Telephone
County
Claim Number
Street 1
Bureau Code
FEINDATE OF THIS NOTICE:
Name
Firm Name
Street 1
Street 2
City/Town
Telephone PA Attorney ID Number
State Zip Code
Name
Firm Name
Street 1
Street 2
City/Town
Telephone PA Attorney ID Number
First Name
Telephone
763 1297-1
You are hereby notified that your workers' compensation benefits are reinstated as of
You are hereby notified that your workers' compensation benefits are resumed as of
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Rev 4-30-98
COMMONWEALTH OF PENNSYLVANIADEPARTMENT OF LABOR AND INDUSTRY
BUREAU OF WORKERS’ COMPENSATION1171 South Cameron Street, Room 310
Harrisburg, PA 17104-2501
IMPAIRMENT RATING EVALUATION FORMS(LIBC-764, 765, 766 AND 767)
REPRODUCTION INSTRUCTIONS
IRE FORMS ON INTERNET:The IRE forms are available in soft copy on the Internet at www.li.state.pa.us/BWC/forms.html. You may access them and provide the file(s) to your printing company, or your printing company may access them directly. These files are provided for your convenience only. The software that you import these files into and/or other factors may determine the accuracy of the final product. If you have any questions regarding obtaining the soft copy of the form file(s) from the Internet, you may call the Bureau Helpline at the appropriate number listed below.
IRE FORMS PREPARATION:The forms for submission to the Bureau may not be photocopied. Original documents must be used for the bar code to effectively process the form upon submission to the Bureau. Forms which are two sided (duplexed) may not be submitted to the Bureau as separate sheets. Duplexed forms must be submitted to the Bureau in exactly the format provided herein.
BAR CODE AND PAPER:Height:.5 inchWidth: 10 mil (Width is the width of the narrowest bar in thousands of an inch)Bar Code Standard: 3 of 9 (Also known as “Code 39” and “Code 3 from 9”)Placement: Must be as shown on the examples.Appearance: Bar Code must be crisp and distinct in order to be accurately read.Paper: Use 20 lb., non-glossy, bright white paper.
FORMS TESTING:The Bureau encourages you to submit advance copies of your forms for testing to assure accuracy of the bar code and format. We have established a Post Office Box for you to send forms for testing. The address is:
Bureau of Workers’ CompensationPO Box 15121
Harrisburg, PA 17105-5121Please allow approximately two weeks for the testing process results to be mailed back to you.
BUREAU HELPLINE TELEPHONE NUMBERS:Within Pennsylvania at 1-800-482-2383Outside of Pennsylvania at 717-772-4447
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Rev 4-30-98
COMMONWEALTH OF PENNSYLVANIADEPARTMENT OF LABOR AND INDUSTRY
BUREAU OF WORKERS’ COMPENSATION1171 South Cameron Street, Room 310
Harrisburg, PA 17104-2501
NOTICE TO ALL INSURANCE CARRIERS, TPAs, AND SELF INSUREDEMPLOYERS
The Bureau is involved in a multi-year contract to automate and expedite as much of our business as possible in an effort to better serve the entire Workers’ Compensation community.
In conjunction with this effort and the passage of Act 57, major changes to many of the existing forms and creation of several new forms are necessary. Among the new forms created are those relative to the Impairment Rating Evaluation (IRE) program as delineated in Section 306 (a.2)(I) of the Workers’ Compensation Act. The forms to be used in conjunction with the IRE program are:
• Notice of Change in Workers’ Compensation Disability Status (LIBC-764)• Impairment Rating Evaluation Appointment (LIBC-765)• Request for Designation of a Physician to Perform an Impairment Rating Evaluation
(LIBC-766)• Impairment Rating Determination Face Sheet (LIBC-767)
Enclosed are two samples of each form: LIBC-764, LIBC-765, LIBC-766, and LIBC-767 and Reproduction Instructions. In accordance with Section 121.4 of the Rules and Regulations “Reproduction of Forms” reproductions will be in accordance with the guidelines that accompany the samples.
It is important that the IRE program forms be reproduced in accordance with the attachedsamples with special attention to the bar code. The IRE form file(s) on soft copy are available at www.li.state.pa.us/BWC/forms.html to be downloaded and taken to your printer for replication.
• Notice of Change in Workers’ Compensation Disability Status (LIBC-764)The insurer shall complete Form (LIBC-764) “Notice of Change in Workers’ Compensation Disability Status” to adjust the status of the employe’s benefits from total to partial disability if the IRE results in an impairment rating of less than 50% whole body impairment. The insurer shall provide notice to the employe, employe’s counsel, if known, and the Bureau.
Page 2Notice of IRE Forms
• Impairment Rating Evaluation Appointment (LIBC-765)The Impairment Rating Evaluation Appointment shall be used by the insurer to request the employe’s attendance at the IRE in writing. It shall specify date, time and location of the evaluation and the name of the physician performing the evaluation, as agreed by the parties or designated by the Bureau. The Appointment notices shall be provided to the employee, employe’s attorney, if known, and the IRE Physician.
• Request for Designation of a Physician to Perform Impairment Rating Evaluation (LIBC-766)The insurer is responsible for scheduling the initial IRE. Only the insurer may request that the Bureau designate an IRE physician. The Bureau’s duty to designate the IRE physician pertains only to the initial IRE. The request to designate a physician to perform an IRE shall be made on Form (LIBC-766) “Request for Designation of a Physician to Perform Impairment Rating Evaluation”. Within 20 days of receipt of the request, the Bureau will designate a physician to perform the IRE.
• Impairment Rating Determination Face Sheet (LIBC-767)The physician performing the IRE shall complete form LIBC-767, “Impairment Rating Determination Face Sheet”, which sets forth the impairment rating of the compensable injury. The physician shall attach to the Face Sheet the “Report of Medical Evaluation” as specified in the AMA Guides. The Face Sheet and report shall be provided to the employee, employe’s counsel, if known, insurer and the Bureau, within 30 days from the date of the impairment evaluation.
Utilization and submission of the new IRE Forms will begin immediately. If you have any questions please contact the Bureau Helpline within Pennsylvania at 1-800-482-2383 and outside of Pennsylvania at 717-772-4447.
Sincerely,
Richard A. Himler, DirectorBureau of Workers’ Compensation
enclosures
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department of labor & industry bureau of workers’ compensation
authorization for alternative delivery of compensation payments
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -WCAIS CLAIM NUMBER
- -DATE OF INJURY
employee
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
DATE OF AUTHORIZATION
- -MM DD YYYY
MM DD YYYY
employer
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
insurer or third party administrator (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
I, , hereby authorize and agree that the checks for the compensation payments due Claimant name (please print)
to me shall be forwarded to me in the following designated manner:
I will pick up my checks at (please check only one box): employer office insurer office
The employer/insurer will mail my checks to me at:
The employer/insurer will direct deposit my checks to the account at the financial institution supplied on the attached authorizationfor direct deposit. (Attach authorization for direct deposit provided by your financial institution.)
Other:
LIBC-10 REV 09-13 (Page 1)
I understand that my employer/insurer is required to mail my compensation checks to my last known address and that I am not under any obligation to authorize the method of delivery outlined above.
Claimant’s signature Claimant’s name (typed/printed)
Employer/Insurer representative’s signature Employer/Insurer representative’s name (typed/printed)
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
employer information claims information services hearing impaired email services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*10* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-10 REV 09-13 (Page 2)
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FINAL STATEMENT OF ACCOUNT OF COMPENSATION PAID
COMMONWEALTH OF PENNSYLVANIADEPARTMENT OF LABOR & INDUSTRY
BUREAU OF WORKERS’ COMPENSATION1171 S. CAMERON STREET, ROOM 103
HARRISBURG, PA 17104-2501(TOLL FREE) 800-482-2383
TTY 800-362-4228
EMPLOYEE SOCIAL SECURITY NUMBER
DATE OF INJURY
MONTH DAY YEARPA BWC CLAIM NUMBER (IF KNOWN)
EMPLOYEE EMPLOYER
First Name
Last Name
Address
Address
City/Town
County
Telephone
State Zip
NOTICE: A Final Statement of Account shall be filed after the final payment of compensation.
INSURER or THIRD PARTY ADMINISTRATOR (if self insured)
Name
Address
Address
City/Town
County
Telephone
State Zip
FEIN
Name
Address
Address
City/Town
Telephone
County
State Zip
FEINClaim #
Bureau Code
( )( )
( )
This is to certify that the above named employer or insurer has paid compensation under the Pennsylvania Workers’ Compensation Act in the above case as follows:
*Additional payment periods or remarks should be indicated on the reverse side of this form.
Rate From Date To Date #Wks #Days Total
Medical Payments
Indemnity Payments
Other Payments
TOTAL COMPENSATION PAID $
$
$
$ .
.
.
.
.
.
.
.
.
.
392A 0908LIBC-392A REV 9-08 (Page 1)
Remarks/Additional Information:
Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under
18 Pa. C.S.A. §4117 (relating to insurance fraud).
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
Name of Employer/Insurer Representative
Signature of Employer/Insurer Representative Month Day Year
DATE
392A 0908
LIBC-392A REV 9-08 (Page 2)
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2-1
DEPARTMENT OF LABOR & INDUSTRYBUREAU OF WORKERS’ COMPENSATION
AGREEMENT FOR COMPENSATIONFOR DISABILITY ORPERMANENT INJURY
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY
MM DD YYYY
WCAIS CLAIM NUMBER
EMPLOYEE EMPLOYER
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
INJURY INFORMATION
Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
Name
Address
Address
City/Town State ZIP
County Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
NOTICE: Agreement should be clearly completed, (preferably typed) and uploaded in accordance with the provisions of the EDI Implementation Guide. A copy must be sent to the employee. Wage information must be completed in accordance with the Pennsylvania Workers’ Compensation Act, and sent to the employee.
DATE DISABILITY BEGAN
The employer shall pay the employee compensation at a rate of $ per week on an average weekly wage of
$ beginning .
MM DD YYYY
MM DD YYYY
Date first check mailed . If the date exceeds the 21-Day Rule, check this boxAnd explain under “further matters agreed upon” on reverse.
Payment of medical and hospital expenses are subject to the limits of time and amount provided by the Pennsylvania Workers’ Compensation Act and subject to modification or termination with the Act.
Compensation payable for weeks days for loss or loss of use of under Section 306(c).
Compensation payable for weeks days for healing period for loss or loss of use of under Section 306(c).
Compensation payable for weeks days for disfigurement under Section 306(c). Please describe the disfigurement.
LIBC-336 REV 09-13 (Page 1)
- - - -
- -
- -
2-2
Further matters agreed upon:
We, the undersigned, agree upon the matters represented herein by the above named employee and the above named employer.
Employee’s signature
Date of agreement
MM DD YYYY
Claims Representative’s signature Claims Representative’s name (typed/printed)
Telephone
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer InformationServices
717.772.3702
Claims Information Servicestoll-free inside PA: 800.482.2383local & outside PA: 717.772.4447
Hearing Impairedtoll-free inside PA TTY: 800.362.4228local & outside PA TTY: 717.772.4991
*336*Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/ProgramLIBC-336 REV 09-13 (Page 2)
- -
2-3
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION
SUPPLEMENTAL AGREEMENT FOR COMPENSATION FOR DISABILITY
OR PERMANENT INJURY
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- - - -
DATE OF INJURY WCAIS CLAIM NUMBER
MM DD YYYY
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
INJURY INFORMATION
Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
NOTICE: Agreement should be clearly completed, (preferably typed) and uploaded in accordance with the provisions of the EDI Implementation Guide. A copy must be sent to the employee. Weekly wages must be completed in accordance with the Pennsylvania Workers’ Compensation Act.
Whereas, the undersigned employer and employee hereby agree that the status of the employee’s disability changed on
as follows: Suspended, returned to work, no loss of wages Termination - -Modification Recurred
Specific loss MM DD YYYY
Said employer shall pay employee compensation at the rate of $ per week beginning on
- -MM DD YYYY
Compensation is payable for weeks days; or, if the future period of disability is uncertain, then to continue at said-rate until further changed by supplemental agreement, final receipt, or order of a Workers’ Compensation Judge, or the Workers’ Compensation Appeal Board.
LIBC-337 REV 09-13 (Page 1)
The employee’s new partial compensation is based on the employee’s present weekly earnings and is calculated as follows:
Calculation: Average weekly wage at time of injury
Minus: Present weekly earnings
Subtotal
x 2/3= New partial compensation rate (subject to the maximum benefit)
Further matters agreed upon (list any previously unreported periods of compensation and/or actions in chronological order, as well as additional information):
We, the undersigned, agree upon the matters represented herein by the above named employee and the above named employer.
Date of agreement
- -MM DD YYYY
Employee’s signature
Claims Representative’s signature Claims Representative’s name (typed/printed)
Telephone
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*337* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-337 REV 09-13 (Page 2)
2-4
DEPARTMENT OF LABOR & INDUSTRYBUREAU OF WORKERS’ COMPENSATION
AGREEMENT FOR COMPENSATION FOR DEATH
DECEASED’S SOCIAL SECURITY NUMBER OR WC ID NUMBER
- - - -DATE OF INJURY WCAIS CLAIM NUMBER
MM DD YYYY
DECEASED EMPLOYEE EMPLOYER
First name
Last name
Date of birth
MM DD YYYY
Date of death
MM DD YYYY
DEPENDENT/GUARDIAN/PERSONAL REPRESENTATIVE
First name
Last name
Address
Address
City/Town State ZIP
County Telephone
INJURY INFORMATION
Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
NOTICE: Agreement should be clearly completed, (preferably typed) and uploaded in accordance with the provisions of EDI Implementation Guide. A copy must be sent to the dependent/guardian/personal representative. Wage information must be completed in accordance with Section 309 of the Pennsylvania Workers’ Compensation Act, and sent to the Dependent/Guardian/Personal Representative.
We, the following persons, dependents of the aforementioned deceased employee, and the undersigned employer, agree upon the following matters which determine dependents’ rights to compensation and its amount and duration.
Employer Representative’s signature
NAME RESIDENCEDATE OF BIRTH
MM-DD-YYYY RELATIONSHIP
- -
- -
LIBC-338 REV 09-13 (Page 1)2-5
.
The compensation payable under the agreed facts, based on the average weekly wage of $ , is as follows:
$ $
$ $
$ $
$ $
$ $
$ $
$ $
- -
- - MM DD YYYY
- - MM DD YYYY
Compensation was paid beginning and ending for the employee’s
disability prior to death.
WEEKLY RATEFROM
MM-DD-YYYYTHROUGHMM-DD-YYYY #WEEKS/#DAYS REASON FOR CHANGE AMOUNT
Amount expended for medical $ Amount expended for burial $
Further matters agreed upon:
Date of agreement
MM DD YYYY
Dependent/Guardian/Personal Representative’s signature
Claims Representative’s signature
Claims Representative’s name (typed/printed)
Telephone
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud)
Employer InformationServices
717.772.3702
Claims Information Servicestoll-free inside PA: 800.482.2383local & outside PA: 717.772.4447
Hearing Impairedtoll-free inside PA TTY: 800.362.4228local & outside PA TTY: 717.772.4991
*338*Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/ProgramLIBC-338 REV 09-13 (Page 2)
2-6
DEPARTMENT OF LABOR & INDUSTRYBUREAU OF WORKERS’ COMPENSATION
SUPPLEMENTAL AGREEMENT FOR COMPENSATION FOR DEATH
DECEASED’S SOCIAL SECURITY NUMBER OR WC ID NUMBER
- - - -DATE OF INJURY
MM DD YYYY
WCAIS CLAIM NUMBER
DECEASED EMPLOYEE EMPLOYER
First name
Last name
Date of birth
Date of death
DEPENDENT/GUARDIAN/PERSONAL REPRESENTATIVE
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
- -
- - MM DD YYYY
- - MM DD YYYY
First name
Last name
Address
Address
City/Town State ZIP
County Telephone
INJURY INFORMATION
Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
NOTICE: Agreement should be clearly completed, (preferably typed) and uploaded in accordance with the provisions of EDI Implementation Guide. A copy must be sent to the employee. Wage information must be completed in accordance with Section 309 of the Pennsylvania Workers’ Compensation Act, and sent to the Dependent/Guardian/Personal Representative.
We, the following persons, dependents of the aforementioned deceased employee, and the undersigned employer, are parties to a compensation agreement or award which is changed because on
MM DD YYYY
the dependent,
Died Remarried A posthumous child was born Other
LIBC-339 REV 09-13 (Page 1)2-7
LIBC-339 REV 09-13 (Page 2)
It is now agreed that compensation shall be payable as follows:
WEEKLY RATEFROM
MM-DD-YYYYTHROUGHMM-DD-YYYY #WEEKS/#DAYS REASON FOR CHANGE AMOUNT
$ $
$ $
$ $
$ $
$ $
$ $
$ $
The above compensation shall be payable from to .- - MM DD YYYY
- - MM DD YYYY
- -
Further matters agreed upon:
Date of this agreement
MM DD YYYY
Dependent/Guardian/Personal Representative’s signature
Claims Representative’s name (typed/printed)
Claims Representative’s signature Telephone
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected] 717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*339*Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
2-8
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION
AGREEMENT TO STOP WEEKLY WORKERS’
COMPENSATION PAYMENTS FINAL RECEIPT
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -WCAIS CLAIM NUMBER
- -DATE OF INJURY
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
NOTICE TO EMPLOYEE Signing this form means your weekly workers’ compensation payments will stop. You may file a petition to reopen your claim within three years of the date to which payments were made.
SIGN THIS FORM IF: Beginning and ending dates and total amount paid shown below are correct; AND you have fully recovered from your injury or disease.
DO NOT SIGN THIS FORM IF: You have returned to work, but are earning less due to work related injury; OR your employer or the insurance company is withholding your last workers’ compensation check unless you sign this form.
MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
Notice: Agreement should be clearly completed (preferably typed) and uploaded in accordance with the provisions of the EDI Implementation Guide. A copy must be mailed to the employee.
The employee received from the above named EMPLOYER/INSURER the sum of $ as final payment of compensation due under the Pennsylvania Workers’ Compensation Act for the injury or disease incurred in the above case. The total amount of compensation received, including the final payment above, is $ in disability benefits for wage loss covering a
period of weeks days from the date my disability began on until the employee was MM DD YYYY
able to return to work on without loss of earning power due to the injury or disease incurred. MM DD YYYY
- -
- -
Notice: The employer/insurance company hereby agrees that no representations have been made to the employee other than those contained in this agreement and that this complies with the Workers’ Compensation Act and Rules and Regulations.
Employee’s signature
MM DD YYYYEmployer/Claims Representative’s signature
- -
Employer/Claims Representative’s name (typed/printed) Telephone
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*340*Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program
LIBC-340 REV 09-13 2-9
2-10
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION
THIRD PARTY SETTLEMENT AGREEMENT
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth If deceased - Dependent/Guardian/Personal Representative First name
Last name
Address
Address
City/Town State ZIP
County Telephone
NOTICE: Agreement should be clearly completed (preferably typed) and uploaded in accordance with the provisions of the EDI Implementation Guide. A copy must be sent to the employee.
EMPLOYEE’S ATTORNEY
Name
Firm name
Address
Address
City/Town State ZIP
Telephone
PA Attorney ID number
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
INSURER’S ATTORNEY
Name
Firm name
Address
Address
City/Town State ZIP
Telephone
PA Attorney ID number
LIBC-380 REV 09-13 (Page 1) 2-11
CALCULATION INSTRUCTIONS
#1 --#2 --
#3 --
#4 to #8 --
Enter the total amount of money received by the employee from the third-party litigation. Enter the total amount of indemnity and medical benefits paid by the employer to the employee at the time of third-party recover. Enter attorney fees and other expenses paid by the employee to obtain recovery in the third-party action. Perform the calculations in the right column and enter the results into the center column.
In accordance with section 319 of the Pennsylvania Workers’ Compensation Act, the parties herein have agreed to the following distribution of proceeds received from , third party.
BASIC RECOVERY INFORMATION — Complete this section for all third-party settlements.
1. Total amount of third-party recovery 1.
2. Accrued workers’ compensation lien 2.
a. indemnity benefits
b. medical benefits
3. Expenses of recovery 3.
4. Balance of recovery 4. = #1 (minus) #2
PRESENT DISTRIBUTION OF PROCEEDS — Complete this section to calculate the amount of proceeds the employer is to receive as of (date through which accrued workers compensation lien [#2] calculated).
5. Accrued lien expense reimbursement rate 5. % = #2 (divided by) #1 x 100
6. Expenses attributable to accrued lien 6. = #3 (times) #5
7. Net lien (amount employer to receive) 7. = #2 (minus) #6
FUTURE DISTRIBUTION OF PROCEEDS — Complete this section to calculate how much the employer must reimburse the employee for expenses used to acquire the third party recovery on future compensation liability. Note: This section is to be completed only if the total amount of the third-party recovery (#1) is greater than the amount of the accrued workers’ compensation lien (#2).
8. Reimbursement rate on future compensation liability 8. % = #3 (divided by) #1 x 100
9. The employer/insurer is responsible for percent (#8) of any future weekly benefits and medical expenses to satisfy its obligation to reimburse its pro rata share of employee’s fees and expenses until the subrogation interest is exhausted; (#4). Thereafter, the employer/insurer is responsible for 100 percent of any compensation liability.
Further Matters Agreed Upon:
Date of this agreement
- -MM DD YYYY
Employee’s signature
Employer/Insurer Representative’s Attorney’s signature
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer/Insurer Representative’s signature
Telephone
Employee’s Attorney signature
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991
Email [email protected]
*380* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-380 REV 09-13 (Page 2)
2-12
COMMONWEALTH OF PENNSYLVANIA COMMUTATIONDEPARTMENT OF LABOR AND INDUSTRYBUREAU OF WORKERS' COMPENSATION OF1171 S. CAMERON STREET, ROOM 103
HARRISBURG, PA 17104-2501YYYYMM DDCOMPENSATION
(TOLL FREE) 800-482-2383 (IF KNOWN)
EmployerEmployee
State Zip CodeState Zip Code
Insurer or Third Party Administrator (if self-insured)
Zip CodeState
A copy of this notice of
Pursuant to Section 412 of the Pennsylvania Workers' Compensation Act, future installments of compensation payable to the above employee not being in excess of 52 weeks, the employer/insurer indicated above hereby advises the above employee of its intent to immediately pay in one sum such future installments without discount.
, is presently payable underCompensation for this injury,
Compensation paid to date of this notice:
Compensation due in future:
$
YYYYDDMM
Employer Authorized Agent for Insurer or TPA (if self-insured)
SignatureSignature
Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994.
LIBC-498 REV 12-97
commuted, and the original filed with the Bureau.is to be sent to the employee with full payment of compensationCommutation of Compensation
Social Security Number:
Date of Injury:
PA BWC Claim Number:
NATURE OF INJURY
weeks days.
weeks days.
weeks days @ $ per week for a total of
DATE OF THIS NOTICE:
First Name Last Name First Name Last Name
First Name Last Name
Street 1
Street 2
City/Town
County Telephone
Name
Street 1
Street 2
City/Town
Telephone
County
FEIN
Name
Street 1
City/Town
Telephone
County
Claim Number
Bureau Code
FEIN
Street 2
Notice of Compensation Payable or Agreement for weeks
to be paid in one sum without discount.
498 1297-1
American LegalNet, Inc.www.USCourtForms.com
2-13
2-14
department of labor & industry workers’ compensation office of adJudication
COMPROMISE AND RELEASE AGREEMENT BY STIPULATION
PURSUANT TO SECTION 449 OF THE WORKERS’ COMPENSATION ACT
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
NOTICE: SUBMIT TO THE ASSIGNED WORKERS’ COMPENSATION JUDGE.
TO THE EXTENT THIS AGREEMENT REFERENCES AN INJURY FOR WHICH LIABILITY HAS NOT BEEN RECOGNIZED BY AGREEMENT OR BY ADJUDICATION, THE TERM “INJURY” AS USED IN THIS AGREEMENT SHALL MEAN “ALLEGED INJURY.”
“FUND” SHALL MEAN THE UNINSURED EMPLOYERS GUARANTY FUND (UEGF), SELF-INSURANCE FUND (SIF), SELF-INSURANCE GUARANTY FUND (SIGF) OR THE PREFUND ACCOUNT OF THE SELF-INSURANCE GUARANTY FUND.
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER, FUND or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
This is an agreement in the case of the above listed employee and the above listed employer, insurer, Fund or third party administrator in regards to an injury or occupational disease.
1. State the date of injury or occupational disease. - -MM DD YYYY
2. State the average weekly wage of the employee, as calculated under Section 309. $ . /wk
3. State the weekly compensation rate paid or payable. $ . /wk
4. State the precise nature of the injury and whether the disability is total or partial.
5. State the amount of benefits paid or due and unpaid to the employee or dependent up to the data of this agreement or
death. Wage Loss: $ . Specific Loss: $ . Medical: $ .
LIBC-755 REV 09-13 (Page 1) 2-15
6. Is this Compromise and Release Agreement a resolution of wage loss benefits for the injury referenced in paragraphs 1 and 4? Yes No
7. Is this Compromise and Release Agreement a resolution of medical benefits for the injury referenced in paragraphs 1 and 4? Yes No
8. Is this Compromise and Release Agreement a resolution of specific loss benefits for the injury referenced in paragraphs 1 and 4? Yes No
9. Does this claim arise out of the death of an employee? Yes No If yes, complete and attach a Death Claim Supplement.
10. Summarize all wage loss, specific loss and medical benefits to be paid in conjunction with this Compromise and Release Agreement:
11. Is there an actual or potential lien for subrogation under Section 319? Yes No If yes, state (if known) the total amount of compensation, including medicals, paid or payable, which would be allowed to the employer or insurer.
12. Are there any current child or spousal support orders in place against the employee? Yes No
Verification pursuant to Special Rules of Administrative Practice and Procedure before Workers’ Compensation Judges, Rule 131.111(c), must be attached.
If yes, provide details:
13. List all benefits received by, or available to the employee; e.g. Social Security (disability or retirement) private health insurance, Medicare, Medicaid, etc.
LIBC-755 REV 09-13 (Page 2)
2-16
14. This Compromise and Release Agreement addresses the interests of Medicare in accordance with the Medicare Secondary Payer Statue (42 U.S.C. Section 1395(y)):
(a) Manner in which Medicare’s interests have been addressed:
(b) Amount allocated: $ . .
(c) Manner is which conditional payments have been addressed:
15. Check as appriopriate:
A vocational evaluation of the employee was completed in conjunction with this Compromise and Release Agreement on
- - by . A copy of this report must be attached.
-OR-
A vocational evaluation of the employee has been waived by mutual agreement of the parties.
16. State the issues involved in this claim and the reasons why the parties are entering into this agreement.
17. A copy of the fee agreement between employee and counsel must be attached. State the amount of the fee: $ . .
18. Litigation costs in the total amount of $ . shall be the responsibility of .
19. State additional terms and provisions, if any:
REMINDER TO PARTIES: Upon approval of the agreement, please promptly withdraw all appeals pending before the Workers’ Compensation Appeal Board, Commonwealth Court, Pennsylvania Supreme Court, etc., which are also resolved by this agreement.
LIBC-755 REV 09-13 (Page 3) 2-17
EMPLOYEE’S CERTIFICATION
1. I certify that I have read this entire agreement, or to the best of my knowledge, information and belief (if applicable) this agreement has been read to me, and I understand all the contents of this agreement as well as the full legal significance and consequences of entering into this agreement.
2. I understand that, if this agreement is approved, I will receive only the benefits mentioned in this agreement, unless the agreement provides specifically for additional amounts. I understand that my employer, its insurance company or its administrator will never have to pay any other workers’ compensation benefits for the injury.
3. Except for the amounts of benefits listed in this agreement, I have been offered nothing of value to convince me to sign this agreement.
4. I have been represented by an attorney of my own choosing during this case. My attorney has explained to me the content of this agreement and its effects upon by rights. (Employee’s Initials)
-OR-I have not been represented by an attorney of my own choosing. However, I have been told that I have the right to be represented by an attorney of my own choosing in this proceeding. I have made my own decision not to have an attorney represent me. (Employee’s Initials)
5. Unless specifically stated in this agreement, I understand that this agreement is a compromise and release of a workers’ compensation claim, and is not considered an admission of liability by employer and/or insurer and/or administrator and/or fund.
DO NOT SIGN THIS DOCUMENT UNLESS YOU UNDERSTAND THE FULL LEGAL SIGNIFICANCE OF THIS AGREEMENT
All parties have read this agreement and agree to its contents. We understand that under this agreement, all petitions are resolved unless specifically agreed to herein. A list of any petitions or issues that remain open after approval of the Compromise and Release Agreement must be provided in this agreement.
DATE
- -MM DD YYYY Employee’s signature
Witness to employee’s signature
Witness to employee’s signature
Employee’s counsel signature
Fund/Employer/Insurer/Third Party Administrator’s signature
Fund/Employer/Insurer/Third Party Administrator counsel’s signature
If not witnessed above, this agreement must be notarized as follows:
AFFIDAVIT/ACKNOWLEDGMENT:
Before me, the undersigned notary public, in and for the aforesaid county and state, personally appeared who being first duly sworn, does depose and state that he/she knows (or has satisfactorily proven to be) the individual identified as the employee in the foregoing compromise and release agreement; and that he/she has executed the foregoing compromise and release agreement for the purposes stated herein:
Notary Public
THE COMPROMISE AND RELEASE AGREEMENT IS NOT VALID AND BINDING UNLESS APPROVED BY A WORKERS’ COMPENSATION JUDGE IN A DECISION.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991
Email [email protected]
*755* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-755 REV 09-13 (Page 4)
2-18
www.FormsWorkFlow.comLIBC-749 REV 02-11 (Page 1)
DEATH CLAIMSUPPLEMENT TO
COMPROMISE ANDRELEASE AGREEMENT
COMMONWEALTH OF PENNSYLVANIADEPARTMENT OF LABOR & INDUSTRY
BUREAU OF WORKERS’ COMPENSATION1171 S. CAMERON STREET, ROOM 103
HARRISBURG, PA 17104-2501(TOLL FREE) 800.482.2383
TTY 800.362.4228www.dli.state.pa.us
TO THE PARTIES: THIS SUPPLEMENTMUST BE COMPLETED AND ATTACHEDTO THE COMPROMISE AND RELEASEAGREEMENT FORM (LIBC 755) IN ALLCLAIMS ARISING OUT OF THE DEATH OFAN EMPLOYEE.
TO THE EXTENT THIS AGREEMENT REFERENCES AN INJURY FOR WHICH LIABILITY HAS NOT BEEN RECOGNIZED BY AGREEMENT OR BY ADJUDICATION, THE TERM “INJURY” AS USED IN THIS AGREEMENT SHALL MEAN “ALLEGED INJURY.”
“FUND” SHALL MEAN THE UEGF, SIF, SIGF OR PRE-SIGF.
This form must be used as of February 1, 2011. Prior versions of the form will no longer beaccepted.
1. Date of death: ______/ ______/ _________
2. Name and address of the widow or widower (include any maiden names, aliases and name upon remarriage, if applicable):
3. Names, addresses and dates of birth of all children:
MM DD YYYY
Employee
Date of Injury:
PA BWC Claim Number:
MM DD YYYY
(IF KNOWN)
/ /
EmployerName
Street 1
Street 2
City/Town State Zip Code
County
Telephone FEIN
-
( ) -
Insurer, Fund or Third Party Administrator (if self-insured)Name
Street 1
Street 2
City/Town State Zip Code
County
Telephone Bureau Code
Insurer/TPA Claim Number FEIN
-
( ) -
First Name Last Name
Street 1
Street 2
City/Town State Zip Code
County Telephone
( ) -
-
2-19
www.FormsWorkFlow.com
4. If it is claimed that the dependency of any child continues beyond the age of eighteen (18) years,
5. State the name, address and relationship to the employee of any other person claiming to be a dependent, (other than those individuals listed in items 2, 3 and 4 above) together with a brief summary of the factual basis for this claim.
6. Has a guardian been appointed for any child or dependent? Yes No If Yes, a copy of appointing Order must be attached.
All parties have read this agreement and agree to its contents.
Dated: ______ / ______ / ________ ____________________________________________
_______________________________________________ ____________________________________________
_______________________________________________ ____________________________________________
____________________________________________
If not witnessed above, this agreement must be notarized as follows:
AFFIDAVIT/ACKNOWLEDGMENT:
Before me, the undersigned Notary Public, in and for the aforesaid County and State, personally appeared
agreement; and that he/she has executed the foregoing compromise and release agreement for the purposes stated herein.
_______________________________________
THE COMPROMISE AND RELEASE AGREEMENT IS NOT VALID AND BINDING UNLESS APPROVED BY A WORKERS’ COMPENSATION JUDGE IN A DECISION.
WITNESS TO WIDOW / WIDOWER / GUARDIAN SIGNATURE
WITNESS TO WIDOW / WIDOWER / GUARDIAN SIGNATURE
WIDOW / WIDOWER / GUARDIAN SIGNATURE
WIDOW / WIDOWER / GUARDIAN COUNSEL SIGNATURE
FUND/EMPLOYER/INSURER/THIRD PARTY ADMINISTRATOR (SIGNATURE)
FUND/EMPLOYER/INSURER/THIRD PARTY ADMINISTRATOR COUNSEL (SIGNATURE)
MM DD YYYY
NOTARY PUBLIC
LIBC-749 REV 02-11 (Page 2)
Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program
2-20
employee report of wagesdepartment of labor & industry bureau of workers’ compensation and physical condition
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
employee
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
failUre to complete this form may sUBJect yoU to article Xi of the wc act relating to fraUd.
yoU mUst complete and retUrn this form within 30 days of Beginning employment or self-employment
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
employer
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
insUrer or third party administrator (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
1. Are you now employed? Yes No
2. Are you now self-employed? Yes No
3. Have you been employed or self-employed at any time while receiving workers’ compensation benefits? Yes NoIf you answered yes to one of the questions, please complete the following:
Occupation(s):
4. Has your physical condition (caused by your work injury) changed? Yes No If yes, attach medical report.
5. Is there any other information you are aware of that is relevant in determining your entitlement to, or amount of compensation?
Yes No
If yes, please explain:
(OVER)
LIBC-750 REV 09-13 (Page 1) 3-1
6. Names of employers for whom you have worked since your date of injury:
Name Name
Address Address
Address Address
City/Town State ZIP City/Town State ZIP
Period of employment: Period of employment:
- -From - -From MM DD YYYY MM DD YYYY
- -To - -To MM DD YYYY MM DD YYYY
Amount of wages $ . Amount of wages $ .
if self-employedName
Address From - -Address MM DD YYYY
City/Town State ZIP
Period of employment: To - -MM DD YYYY
From - -MM DD YYYY Amount of wages $ .
To - -MM DD YYYY
Amount of wages $ .
I verify that this information is true and correct based upon my knowledge, information and belief. I understand false statements are subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities.
employee
First name DATE OF NOTICE
Last name
MM DD YYYYSignature
Section 311.1(A) of the Workers’ Compensation Act requires employees who are receiving workers’ compensation, or who have filleda petition to receive workers’ compensation, to report earnings from employment or self-employment. You must complete and return this form to the sender within thirty (30) days of beginning such employment or self-employment.
employee is to retUrn this completed form to the insUrer or third party administrator shown on the front.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S.
§1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
employer information claims information services hearing impaired email services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
- -
*750* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-750 REV 09-13 (Page 2)
3-2
department of labor & industry bureau of workers’ compensation
EMPLOYEE’S REPORT OF (unemployment compensation, social security [old age],
severance and pension benefits)
BENEFITS FOR OFFSETS
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM.
Section 204 of the Workers’ Compensation Act requires employees receiving wage-loss benefits to report the receipt of unemployment compensation, social security (old age) benefits, severance and pension benefits.
COMPLETE AND RETURN THIS FORM TO THE INSURER OR SELF-INSURED EMPLOYER IDENTIFIED ON THIS FORM.
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
Complete the following information, indicating the type, amount and frequency (i.e.: weekly, biweekly, or other [specify]) of the benefits being received. Include the date such receipt began and ended (if applicable). If you are not receiving a particular type of benefit, indicate by writing “not applicable” or “none” in the appropriate space.
RECEIPT BEGAN RECEIPT ENDEDTYPE OF AMOUNT RECEIVED FREQUENCY DATE DATEBENEFIT (MM/DD/YYYY) (MM/DD/YYYY)
Unemployment Gross $ . Weekly Biweekly Compensation Net $ . Other / / / /
Gross $ . Weekly Biweekly
(old age) Social Security
Net $ . Other / / / /
Gross $ . Weekly Biweekly Severance
Net $ . Other / / / /
Gross $ . Weekly BiweeklyPension
Net $ . Other / / / /
If you are receiving pension benefits from the employer directly liable for your workers’ compensation, indicate the percent of the pension which is funded by the employer or check the box for ‘percentage unknown’.
% Percentage unknown
(OVER)
LIBC-756 REV 09-13 (Page 1) 3-3
Did you “roll over” pension benefits into an IRA Account? Yes No Amount “rolled over” $ . (IRA benefits are not offset until you begin withdrawing them from your account.)
I verify that this information is true and correct, based upon my knowledge, information and belief. I understand false statements are subject to the penalties of 18 Pa. C.S. §4909, relating to unsworn falsification to authorities.
DATE
Employee signature - -
MM DD YYYY
If you are receiving any wages from employment or self-employment, check this box . You must report this to your insurer or self-insured employer. Contact your insurer/employer for that reporting form (LIBC-760).
INSTRUCTIONS
TO EMPLOYEES:
If you are receiving workers’ compensation wage-loss benefits due to an injury which occurred on or after June 24, 1996, you must report the receipt of the following:
• Unemployment compensation benefits
• Social Security (old age) benefits
• Severance benefits paid by the employer directly liable for your workers’ compensation
• Pension benefits to the extent funded by the employer directly liable for your workers’ compensation
Your workers’ compensation benefits may be adjusted if you are receiving any of the above benefits. You are required to acknowledge both the receipt of and changes to any of the benefits listed above through the immediate completion and submission of this form.
FAILURE TO REPORT THE RECEIPT OF OR CHANGES TO ANY OF THE BENEFITS LISTED ABOVE MAY SUBJECT YOU TO PROSECUTION UNDER ARTICLE XI OF THE WORKERS’ COMPENSATION ACT RELATING TO INSURANCE FRAUD.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S.
§1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*756* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-756 REV 09-13 (Page 2)
3-4
depdepartment of labor & industrartment of labor & industryy bureau of wbureau of workers’ corkers’ compensaompensationtion
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE VERIFICATION OF EMPLOYMENT, SELF-EMPLOYMENT
OR CHANgE IN PHYSICAL CONDITION
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
INSTRUCTIONS TO EMPLOYEE:
DO NOT RETURN THIS FORM TO THE BUREAU OF WORKERS’ COMPENSATION.
COMPLETED FORM MUST BE RETURNED TO THE PARTY WHO SENT THE FORM TO YOU WITHIN 30 DAYS OF YOUR RECEIPT OF THIS FORM.
IF YOU DO NOT COMPLETE AND RETURN THIS FORM TO THE PARTY WHO SENT IT TO YOU WITHIN 30 DAYS IT MAY RESULT IN A SUSPENSION OF YOUR COMPENSATION BENEFITS AS PROVIDED BY SECTION 311.1(g) OF THE WC ACT, AS WELL AS PROSECUTION FOR FRAUD UNDER ARTICLE XI OF THE WC ACT.
YOU MAY BE REQUIRED TO COMPLETE AND RETURN THIS FORM EVERY SIX MONTHS.
INSTRUCTIONS TO EMPLOYEE: Section 311.1(d) of the Workers’ Compensation Act requires employees who are receiving workers’ compensation, or have filed a petition to receive workers’ compensation, to verify employment, self-employment, wages and changes to physical condition.
1. Are you currently employed by any employer other than the employer listed above? Yes No
2. Are you currently self-employed? Yes No
3. Have you been employed or self-employed at any time while receiving workers’ compensation benefits? Yes No
4. Has your physical condition (caused by your injury) changed? Yes No
5. Is there other information you are aware of that is relevant in determining your entitlement to, or amount of compensation?
Yes No
(OVER)
LIBC-760 REV 09-13 (Page 1) 3-5
6. Names of employers for whom you have worked since your date of injury:
Name
Address
Address
City/Town State ZIP
Period of employment:
From
To
Amount of wages $
- -MM DD
- -MM DD
.
YYYY
YYYY
Name
Address
Address
City/Town State ZIP
Period of employment:
From
To
Amount of wages $
- -MM DD
- -MM DD
.
YYYY
YYYY
Name
Address
Address
City/Town State ZIP
Period of employment:
- -From
MM DD YYYY
- -MM DD YYYY
To
Amount of wages $ .
IF SELF-EMPLOYED
From
MM
-DD
-YYYY
To
MM
-DD
-YYYY
Amount of wages $ .
I verify that this information is true and correct based upon my knowledge, information and belief. I understand false statements are subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities.
Employee
First name
Last name DATE OF NOTICE
- -Signature
MM DD YYYY
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S.
§1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991
Email [email protected]
*760* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-760 REV 09-13 (Page 2)
3-6
department of labor & industry workers’ compensation office of adJudication
claim petition for workers’ compensation
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
emploYee
First name
Last name
Date of birth
If deceased - Dependent/Guardian/Personal Representative
First name
Last name
Address
Address
City/Town State ZIP
County Telephone
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
emploYer
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Vs. insUrer or tHirD partY aDministrator (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
1. Complete description of injury or illness including all parts of body affected. (If you are seeking additional compensation from the Subsequent Injury Fund for total disability as a result of a previous permanent loss, or loss of use of one hand, one arm, one foot, one leg or one eye, and a subsequent
injury causing loss, or loss of use of, another hand, arm, foot, leg or eye, you must also submit from LIBC-375).
2. If occupational disease, give the last date of employment and/or last date of exposure
with this employer.
3. Give date of injury or onset of disease .
- -MM DD YYYY- -
MM DD YYYY
- -MM DD YYYY
4. How did the injury or disease happen?
Yes No Where? (Be specific)5. Did injury or disease occur on employer’s premises?
6. Notice of your injury or disease was served on your employer on in the following manner:MM DD YYYY
7. What was your job title at the time of injury or disease?
Yes No If yes, list additional employers:8. Were you working for more than one employer at the time of your injury?
- - Yes No If yes, give date .9. Did this problem cause you to stop working?MM DD YYYY
10. Are you back to work with the same employer? Yes No If yes, Regular job Other job/give title
- -
LIBC-362 REV 09-13 (Page 1) 4-1
11. Are you back to work with another employer? Yes No If yes, give name and address of new employer:
.12. What were your wages at the time of injury? $ Hour Day Week
13. If you have returned to work since your injury or illness, are you earning
than you were at the time of injury? Current earnings $ .
14. I am seeking payment for (check all that apply):
Loss of wages
More Same Less
Hour Day Week
- - - -Partial disability from thru (date disability ends) or ongoing. MM DD YYYY MM DD YYYY
- - - -Full disability from thru (date disability ends) or ongoing. MM DD YYYY MM DD YYYY
Medical bills (Attach additional sheet giving name of health care provider, address, type of treatment and amount of bill).
Counsel fees to be paid by the employer.
Loss or loss of use of arm, hand, finger, leg, foot or toe.
Disfigurement (scars) of head, face or neck.
Loss of sight.
Loss of hearing.
Cancer as a firefighter under Act 46 of 2011.
15. Other
16. Is there other pending litigation in this case? Yes No If yes, explain below:
PLEASE ENTER MY APPEARANCE FOR PETITIONER:
Attorney’s name
PA Attorney ID number MM DD YYYY
Firm name
- -Date of petition
Address
Address
City/Town State ZIP
Telephone
Attorney’s signature
notice: This petition must be filled out as fully as possible. If not filing electronically, the original must be sent to the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. You must send a copy to all other parties, and on the attorneys of all other parties, if the attorneys are known. A Proof of Service must be attached. A Proof of Service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if known. Questions regarding the completion of this form may be directed to the Bureau of Workers’ Compensation Claims Information Services.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
employer information claims information services Hearing impaired email services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*362* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-362 REV 09-13 (Page 2)
4-2
DEPARTMENT OF LABOR & INDUSTRYWORKERS’ COMPENSATION OFFICE OF ADJUDICATION
FATAL CLAIM PETITION FOR COMPENSATION BY DEPENDENTS
OF DECEASED EMPLOYEES
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -DATE OF INJURY
MM DD YYYY
WCAIS CLAIM NUMBER
- -
EMPLOYEE EMPLOYER
First name
Last name
Date of birth Date of deathIf deceased - Dependent/Guardian/Personal RepresentativeFirst name
Last name
Address
Address
City/Town State ZIP
County Telephone
U.S. Citizen Yes No
INJURY INFORMATION
Description of injury or illness
Check if occupational disease
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
1. Business of employer
2. Time of injury (hour) a.m. p.m.
3. The cause of death was as given by
4. The deceased employee incurred the following medical bills (give name of health care provider, address, type of treatment and bill in space below) related to the fatality.
GIVE NAME AND ADDRESSES. IF NONE, SO STATE.
5. Expenses for the burial amounted to $ . .
Amount paid by employer $ . .
6. The wages of deceased employee at the time of accident were $ . . hour day week
7. Notice of injury and/or death was given to employer on by
in the following manner
8. Compensation for disability was paid to the deceased from to
Total amount paid was $ . .
- - MM DD YYYY
- - MM DD YYYY
- - MM DD YYYY
NAME OF PERSON REPORTING INJURY/DEATH
STATE WHEN AND TO WHOM NOTICE WAS GIVEN AND IN WHAT MANNER
LIBC-363 REV 09-13 (Page 1)4-3
9. Dependents are as follows:
NAME ADDRESS
DATE OF BIRTH
MM-DD-YYYY RELATIONSHIP US CITIZEN
Yes No
Yes No
Yes No
Yes No
Yes No
10. Their dependency is total partial
11. Petitioner was was not living with the deceased employee at the time of his or her death.
12. The petitioner is is not a widow/widower of the deceased employee.
a. If petitioner is a widow or widower, state where ceremony was performed and give date of marriage.
b. Was marriage a common law marriage? Yes No
13. This is an Act 46 (firefighter cancer) claim
14. Other
15. Is there other pending litigation in this case Yes No If yes, explain below.
PLEASE ENTER MY APPEARANCE FOR PETITIONER:
Attorney’s namePA Attorney ID numberFirm nameAddressAddressCity/Town State ZIP Telephone
Date of petition
MM DD YYYY
Attorney’s signature
Dependent/Guardian/Personal Representative’s signature Dependent/Guardian/Personal Representative’s name (typed/printed)
Notice: This petition must be filled out as fully as possible. The original must be sent to the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. You must serve a copy on all other parties, and on the attorneys of all other parties, if the attorneys are known. A Proof of Service must be attached. A Proof of Service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if known. Questions regarding the completion of this form may be directed to the Bureau of Workers’ Compensation Claims Information Services.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228local & outside PA TTY: 717.772.4991
Email [email protected]
- -
*363*Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/ProgramLIBC-363 REV 09-13 (Page 2)
4-4
DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION
PETITION FOR JOINDER OF ADDITIONAL DEFENDANT
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth If deceased - Dependent/Guardian/Personal Representative First name
Last name
Address
Address
City/Town State ZIP
County
Telephone
“ FUND” SHALL MEAN THE UNINSURED EMPLOYERS GUARANTY FUND, SUBSEQUENT INJURY FUND,
SELF-INSURANCE GUARANTY FUND OR PRE-SELF-INSURANCE GUARANTY FUND.
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
VS. INSURER, FUND or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
Employee Employer hereby petitions for joinder in connection with the pending petition(s):
Additional Employer Additional Insurer Attorney (if known)
Name Name Name
Address Address Firm name
Address Address Address
City/Town State ZIP City/Town State ZIP Address
County County City/Town State ZIP
Telephone Telephone FEIN Telephone
FEIN NAIC code or Insurer code PA Attorney ID number
Additional Employer Additional Insurer Attorney (if known)
Name Name Name
Address Address Firm name
Address Address Address
City/Town State ZIP City/Town State ZIP Address
County County City/Town State ZIP
Telephone Telephone FEIN Telephone
FEIN NAIC code or Insurer code PA Attorney ID number
LIBC-376 REV 09-13 (Page 1) 4-5
Additional Employer Additional Insurer Attorney (if known)
Name Name Name
Address Address Firm name
Address Address Address
City/Town State ZIP City/Town State ZIP Address
County County City/Town State ZIP
Telephone Telephone FEIN Telephone
FEIN NAIC code or Insurer code PA Attorney ID number
Counsel for Employee Attorney’s name PA Attorney ID number Firm name Address Address City/Town State ZIP Telephone
Petitioner or Representative’s signature
Petitioner or Representative’s name (typed/printed)
Counsel for Employer/Insurer (if known)
Attorney’s name PA Attorney ID number Firm name Address Address City/Town State ZIP Telephone
Date filed
- -MM DD YYYY
Notice: This petition must be filled out as fully as possible. The original must be sent to the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. You must serve a copy on all other parties, and on the attorneys of all other parties, if the attorneys are known. A Proof of Service must be attached. A Proof of Service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if know. Questions regarding the completion of this form may be directed to the Bureau of Workers’ Compensation Claims Information Services.
Joinder is requested for the following reasons:
If not filing electronically,
Attached are: Claim and/or other petitions The names/addresses of all parties and their counsel
All answers filed A statement of all hearings held or scheduled and depositions
All exhibits taken with dates and locations
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*376* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-376 REV 09-13 (Page 2)
4-6
DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION
PETITION TO/FOR: (Check any that apply)
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY WCAIS CLAIM NUMBER
- - - -
Modify compensation benefits (Reduce/increase amount of workers’ compensation)
Penalties (For violation of the act, rules and regulations)
Reinstate compensation benefits Review compensation benefits Review compensation benefits offset Review medical treatment and/or billing
This petition is filed on behalf of: Employee
EMPLOYEE
First name
MM DD YYYY
Seek approval of a compromise and release agreement (Ask judge to approve settlement)
Set aside final receipt (Ask judge to set aside agreement to stop compensation)
Suspend compensation benefits Terminate compensation: Based upon physician’s affidavit, a special supersedeas hearing to be scheduled Terminate compensation benefits (Employee fully recovered without any disability)
Employer/Insurer
EMPLOYER
Name
Last name Address
Address Date of birth If deceased - Dependent/Guardian/Personal Representative City/Town State ZIP First name
County Last name
Telephone FEIN Address
VS. INSURER, FUND or THIRD PARTY ADMINISTRATOR (if self-insured) Address
Name City/Town State ZIP
Address County Telephone
AddressINJURY INFORMATION
Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
Provide the following information if Employer has accepted liability for this injury:
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
“FUND” SHALL MEAN THE UNINSURED EMPLOYERS GUARANTY FUND, SUBSEQUENT INJURY FUND, SELF-INSURANCE GUARANTY FUND OR PRE-SELF-INSURANCE GUARANTY FUND.
TO YOUR HONORABLE JUDGE:
The above petitioner requests the workers’ compensation judge to order the above action as of for the following reason(s).
1. Full recovery 10. Medical bills unpaid 2. Specific job offered 11. Medical bills not related 3. Work generally available 12. Worsening of condition 4. Able to return to unrestricted work 13. Injury causing decreased earning power 5. Has returned to work 14. Section 314 order violated 6. Reasonable treatment refused 15. Voluntary withdrawal from workforce 7. Resolution to specific loss 16. Violation of the act, rules and regulations 8. Incorrect description of injury 17. Subrogation, credit or offset for 9. Incorrect average weekly wage UC Social Security Third party recovery
S&A Pension
- -MM DD YYYY
LIBC-378 REV 09-13 (Page 1) 4-7
18. Other
Compensation benefits
being paid
have been paid based on a:
Notice of compensation payable dated
Agreement dated
Supplemental agreement dated
MM
MM
MM
-
-
-
DD
DD
DD
-
-
-
YYYY
YYYY
YYYY
Judge’s order dated
Board order dated
Court order dated
MM
MM
MM
-
-
-
DD
DD
DD
-
-
-
YYYY
YYYY
YYYY
This is an Act 46 (firefighter cancer) claim
Is supersedeas being requested pursuant to Section 413(A.2)?If yes, list reasons:
Yes No
Average weekly wage $
Applicable weekly total disability rate $
.
.
Date of most recent payment
MM
-DD
-YYYY
Amount $ .
PLEASE ENTER MY APPEARANCE FOR PETITIONER:
Attorney’s name PA attorney ID number Firm name Address Address City/Town State ZIP Telephone
COUNSEL FOR RESPONDENT (if known):
Attorney’s name PA attorney ID number Firm name Address Address City/Town State Telephone
ZIP
Petitioner or Representative’s signature MM DD YYYY
Petitioner or Representative’s name (typed/printed)
Notice: This petition must be filled out as fully as possible. If not filing electronically, the original must be sent to the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. You must send a copy to all other parties, and to the attorneys of all other parties, if the attorneys are known. A proof-of-service must be attached. A proof-of-service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their at-torneys, if known. Questions regarding the completion of this form may be directed to Bureau of Workers’ Compensation Claims Information Services.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
- -Date of petition
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Equal Opportunity Employer/Program LIBC-378 REV 09-13 (Page 2)
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LIBC-758 REV 02-11
COMMONWEALTH OF PENNSYLVANIADEPARTMENT OF LABOR & INDUSTRY
BUREAU OF WORKERS’ COMPENSATION1171 S. CAMERON STREET, ROOM 103
HARRISBURG, PA 17104-2501
Please read the attached Petition carefully. It could have an impact on your right to receive workers’
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NOTICE TO EMPLOYEE
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DEPARTMENT OF LABOR & INDUSTRYWORKERS’ COMPENSATION OFFICE OF ADJUDICATION
OCCUPATIONAL DISEASE CLAIM PETITION MONTHLY COMPENSATION FOR
DISABILITY UNDER SECTION 301(i) ONLY
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
INJURY INFORMATION
Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
VS
Commonwealth of Pennsylvania Department of Labor & Industry c/oOfficeofChiefCounsel 1171 South Cameron Street Harrisburg, PA 17104-2501
1. My last date of employment or self-employment in any occupation was .
2. I became totally disabled on as a result of:
Coal Workers’ Pneumoconiosis Silicosis Anthraco-Silicosis Asbestosis
3. My total disability is a result of employment in a hazardous occupation having a:
Coal hazard Asbestos hazard Silica hazard
4. I was employed in the Commonwealth of Pennsylvania at least two years preceding the above date of the disability, as follows:
(List all employment in the hazardous occupation.)
NAME OF EMPLOYER IN PENNSYLVANIA ADDRESS DATES OF EMPLOYMENT
FROM TO MM-DD-YYYY MM-DD-YYYY
- - MM DD YYYY
- - MM DD YYYY
LIBC-396 REV 09-13 (Page 1)4-15
5. IfyouhavefiledaclaimpreviouslyundertheOccupationalDiseaseActortheWorkers’CompensationAct,completethefollowing:
(a)Dateoffiling
(b) Claim petition: Pending Dismissed Withdrawn
(c)Claimfiledunder:OccupationalDiseaseActWorkers’CompensationAct
6. I have have notfiledforbenefitsundertheFederalHealthandCoalMineSafetyActof1969.
- - MM DD YYYY
Therefore, I hereby petition the Department of Labor & Industry to award monthly compensation to me at the rate set forth under the provisions of Section 301 (i) of the 1939 Occupational Disease Act, as amended.
PLEASE ENTER MY APPEARANCE FOR PETITIONER: Date of petitionAttorney’s namePA Attorney ID numberFirm nameAddressAddressCity/Town State ZIP Telephone
- - MM DD YYYY
Attorney’s signature
Notice: This petition must be filled out as fully as possible. If not filing electronically, the original must be sent to the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202, Harrisburg PA, 17102-1400. You must serve a copy to all other parties, and on the attorneys of all other parties, if the attorneys are known. Questions regarding the completion of this form may be directed to the Bureau of Workers’ Compensation Claims Information Services.
INSTRUCTIONS TO CLAIMANT
Failure to comply with these instructions will necessitate the return of your petition.
Employee must sign this document.
Attach two recent photographs. Place your signature and last four digits of Social Security Number on the reverse side of each photograph.
AnyindividualfilingmisleadingorincompleteinformationknowinglyandwiththeintenttodefraudisinviolationofSection1102ofthePennsylvaniaWorkers’CompensationAct,77P.S.
§1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected] 717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
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Equal Opportunity Employer/ProgramLIBC-396 REV 09-13 (Page 2)
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department of labor & industry workers’ compensation office of adjudication
petition for physical examination or expert interview of employee
(section 314) EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY
MM DD YYYY
WCAIS CLAIM NUMBER
- -- -
employee
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
inJUry information Provide the following information if Employer has accepted liability for this injury: Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
employer
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
vs. insUrer or thirD party aDministrator (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
NOTICE TO EMPLOYEE: Employer must indicate whether “physical examination” or “expert interview” is required by checking the appropriate boxes. Employee’s answer must be filed with the Workers’ Compensation Judge within twenty (20) days.
1. The insurer/employer alleges that it requested the employee to submit to a physical examination expert interview
by , HEALTH CARE PROVIDER’S/EXPERTS NAME AND ADDRESS AND FIELD OF SPECIALTY OR EXPERTISE
for the purposes of on , and the employee refused or failed IME/IRE/EXPERT INTERVIEW
to appear at such examaination or interview.
- -MM DD YYYY
2. The date of last physical examination of the employee by the health care provider chosen by the insurer/employer or
- - expert interview of the employee by the expert chosen by the insurer/employer was on . MM DD YYYY
3. If the petition is for the purpose of an IRE, the date of the request was on MM DD YYYY
4. Where, the insurer/employer petitions the workers’ compensation Judge to order the employee to submit to a physical examination an expert interview by or by such health care
HEALTH CARE PROVIDER’S/EXPERTS NAME
provider(s)/expert(s) as may be designated by the Workers’ Compensation Judge at such time and place as may be set and
determined . IME/IRE/EXPERT INTERVIEW
- - .
Identify documents previously filed with the Bureau of Workers’ Compensation:
Notice of Compensation Payable dated
Supplemental Agreement dated
Other dated
Petition dated
MM DD YYYY MM DD YYYY
- -
MM DD YYYY
- -
- -
MM DD YYYY
- -
5. This is an Act 46 (firefighter cancer) claim
LIBC-499 REV 09-13 (Page 1)
4-17
claimant MUST BE serveD
please enter my appearance for petitioner
Attorney’s name
PA Attorney ID number
Firm name
Address
Address
City/Town State ZIP
Telephone
coUnsel for responDent (if known)
Attorney’s name
PA Attorney ID number
Firm name
Address
Address
City/Town State ZIP
Telephone
Petitioner or representative’s signature - -
Date of petition
MM DD YYYY
Petitioner or representative’s name (typed/printed)
NOTE: This petition must be filled out as fully as possible. If not filing electronically, the original must be sent to the Workers’ Compensation Office of Adjudication, 1010 N 7th Street, Suite 202, Harrisburg, PA, 17102-1400. You must send a copy to all other parties, and to the attorneys of all other parties, if the attorneys are known. A proof of service must be attached. A proof of service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if known. Questions regarding the completion of this form may be directed to Bureau of Workers’ Compensation Claims Information Services.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991
Email [email protected]
*499* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-499 REV 09-13 (Page 2)
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COMMONWEALTH OF PENNSYLVANIADEPARTMENT OF LABOR AND INDUSTRYBUREAU OF WORKERS’ COMPENSATION1171 S. CAMERON STREET, ROOM 103
HARRISBURG, PA 17104-2501(TOLL FREE) 800-482-2383
TTY 800-362-4228
APPLICATION FORSUPERSEDEAS FUND
REIMBURSEMENT
Social Security Number: ____ - ___ - ______
Date of Injury: ______/______/____________MM DD YYYY
PA BWC Claim Number: _________________ (IF KNOWN)
LIBC-662 REV 7-07 (Page 1) (OVER)
Employee EmployerName
_________________________________________________________________________________
Street 1
_________________________________________________________________________________
Street 2
_________________________________________________________________________________
City/Town State Zip Code
________________________________________________ _________ ____________-_________
County FEIN
____________________________________________ _____________________
Telephone
(_______)_______-____________________________
Name
_________________________________________________________________________________
Street 1
_________________________________________________________________________________
Street 2
_________________________________________________________________________________
City/Town State Zip Code
________________________________________________ _________ ____________-_________
County FEIN
____________________________________________ _____________________
Telephone
(_______)_______-____________________________
Claim Number
____________________________________________
First Name Last Name
_________________________________ _____________________________________________
Insurer or Third Party Administrator (if self-insured)
TO THE DEPARTMENT OF LABOR AND INDUSTRY, BUREAU OF WORKERS’ COMPENSATION:
As insurer/self-insurer in the above case, we herewith request reimbursement of compensation paid to claimant pursuant to Section 443 of the Pennsylvania Workers’ Compensation Act.
IN SUPPORT OF THE ABOVE REQUEST, WE OFFER THE FOLLOWING FACTS:
Request for supersedeas was filed on _______/_______/____________ in connection with petition or appeal filed on MM DD YYYY
_______/_______/____________ for termination modification suspension of compensation as of _______/_______/__________. MM DD YYYY MM DD YYYY
Insurer’s/self-insurer’s request for supersedeas was
as a result of which insurer/self-insurer continued payment of compensation from _______/_______/___________ until the final MM DD YYYY
outcome of the proceedings on _______/_______/____________ , at which time it was determined that such compensation was MM DD YYYY
not, in fact, payable.
Is there a potential or existing third-party action? Yes No If yes, list docket number ____________(if known).
Insurer/self-insurer verifies that the underlying case is not on appeal, that the appeal period has expired, and there is no other litigation pending which would affect Supersedeas Fund Reimbursement. Insurer/self-insurer affirmatively states that the decision issued by
___________________________________________________________ dated _______/_______/____________ is final. MM DD YYYY
662 0707
SEE INSTRUCTIONS ON REVERSE
This application is filed on behalf of: Insurer Self-Insured Employer
denied on _______/_______/____________MM DD YYYY
granted on _______/_______/____________MM DD YYYY
not acted on (and therefore deemed denied)
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INSURER/SELF-INSURER, THEREFORE, REQUESTS REIMBURSEMENT OF ITS OVERPAYMENT OF COMPENSATION AS FOLLOWS:
Compensation attributable to, and subsequently paid for, _______ weeks and ________ days from _______/_______/__________ MM DD YYYY
to _______/_______/____________ inclusive at $___________.____ per week for TOTAL OF $ ___________.____. During the above MM DD YYYY
time period, medical expenses were incurred, and subsequently paid, for a TOTAL OF $____________.____. Proof
of payment of the above averments are attached hereto. The following unusual payment circumstances, if any,
are:_______________________________________________________________________________________________________
___________________________________________________________________________________________________________
Other matters alleged: ______________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994.
INSTRUCTIONS
All requests for reimbursement from the Supersedeas Fund pursuant to Article IV, Section 443, of the Pennsylvania Workers’ Compensation Act (Act) must be by application on Form LIBC-662, Application for Supersedeas Fund Reimbursement. The Application must be fully completed, including all dates requested. Applicants must verify that the parties have not filed an appeal, and that the decision is final.
Any information that supports the Application, including underlying petitions and decisions, must be attached to the Application. Any information relating to a potential or existing third-party recovery (including but not limited to the third party settlement agreement), compromise and release agreement, or other matter which may affect this application, must also be attached. The claimant’s social security number, BWC Claim Number (if known) and name must be included on each attached page.
Applicant also must file proof of payment, which must be attached to the Application. Proof of payment should be in the form of copies of canceled checks or computer printouts of payment records. Also, proof of payment must include dates of service for indemnity and medical expenses incurred and payee names.
Failure to fully complete the Application or to attach the required supporting documentation and proof of payment will result in the Application being returned without processing.
An Application may be assigned to a Workers’ Compensation Judge for a hearing and determination of eligibility for reimbursement pursuant to the Act.
Name and Title
_________________________________________________________________________________
Phone Number
_________________________________________________________________________________
Signature
_________________________________________________________________________________
Attorney for/Representative of
_________________________________________________________________________________
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LIBC-662 REV 7-07 (Page 2)
SubmitterVERIFICATION
I UNDERSTAND THAT FALSE STATEMENTS HEREIN ARE MADE SUBJECT TO THE PENALTIES OF 18 PA. C.S. §4904 RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES.
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DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION
LIBC-550 REV 09-13 (Page 1)
CLAIM PETITION FOR BENEFITS FROM THE UNINSURED EMPLOYER AND THE UNINSURED EMPLOYERS
GUARANTY FUND
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- - - -DATE OF INJURY
MM DD YYYY
WCAIS CLAIM NUMBER
EMPLOYEE
First name
Last name
Date of birth If Deceased - Dependent/Guardian/Personal Representative First name
Last name
Address
Address
City/Town State ZIP
County
Telephone
EMPLOYER
Name
Address
Address
City/Town State ZIP
VS County
Telephone FEIN
AND
Pennsylvania Uninsured Employers Guaranty Fund PO Box 1774 Harrisburg, PA 17105-1774
Employee should file this petition if they are seeking an award against their employer and the Uninsured Employers Guaranty Fund because their employer did not maintain workers’ compensation insurance coverage and was not approved as a self-insurer at the time of the alleged injury. Note: You may not file this petition until 21 days after you filed a Notice of Claim Against Uninsured Employer, From LIBC-551.
1. Have you filed a Notice of Claim Against the Uninsured Employer, Form LIBC-551? Yes No
2. Complete description of injury or illness including all parts of body affected. If fatality, provide cause of death.
3. If occupational disease, give the last date of employment and/or MM DD YYYY
last date of exposure - -MM DD YYYY
4. Give date of injury or onset of disease
5. How did the injury or disease occur?
- -
- -MM DD YYYY
6. Did injury or disease occur on employer’s premises? Yes No Where? (Be specific)
7. Notice of your injury or disease was served on your employer on MM DD YYYY
in the following manner: - -
8. What was your job title at the time of injury or disease?
9. Were you working for more than one employer at the time of the injury? Yes No If yes, list additional employers:
10. Did this problem cause you to stop working? Yes No If yes, give date.
MM DD YYYY
11. Are you back to work with the same employer? Yes No If yes, Regular job Other job/give title
12. Are you working with another employer? Yes No If yes, give name and address of new employer:
- -
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.13. What were your weekly wages at the time of injury? $
14. Dependents are as follows:
DATE OF BIRTH NAME ADDRESS MM-DD-YYYY RELATIONSHIP US CITIZEN
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
15. If you have returned to work since your injury or illness, are you earning More Same Less
than you were at the time of injury? Current weekly wages $
16. I am seeking payment for (check all that apply):
Loss of Wages - - - -Partial disability from to
MM DD YYYY MM DD YYYY
- - - -Full disability from to MM DD YYYY MM DD YYYY
Medical bills (give name of doctor/hospital, address, type of treatment and bill in space below.)
Counsel fees to be paid by the employer. (Note: The Fund is not subject to unreasonable contest attorney fees.)
Loss or loss of use of arm, hand, finger, leg, foot or toe.
Disfigurement (scars) of head, face or neck. - -Injury or disease resulting in death. Date of death.
MM DD YYYY Loss of sight
Loss of hearing
Cancer as a firefighter under Act 46 of 2011
17. Have you filed any other Workers’ Compensation Petition(s) related to this injury/fatality? Yes No If yes, PA BWC Claim Number (if known) .
PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney’s name PA attorney ID number Firm name Address Address City/Town State ZIP Telephone
Date of petition
MM DD YYYY
A copy of this petition has been sent to the employer and the Fund.
Signature
Employee or Dependent Attorney
Notice: This petition must be filled out as fully as possible. If not filling electronically, the original must be sent to the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202 Harrisburg PA 17102-1400. You must send a copy of this petition to the employer and Guaranty Fund, PO Box 1774, Harrisburg, PA 17105-1774. Questions regarding the completion of this form ma be directed to Bureau of Workers’ Compensation Claims Information Services.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991
Email [email protected]
.
- -
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DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION
LIBC-375 REV 09-13 (Page 1)
CLAIM PETITION FOR ADDITIONAL COMPENSATION FROM THE SUBSEQUENT
INJURY FUND PURSUANT TO SECTION 306.1 OF THE WORKERS’ COMPENSATION ACT
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
DATE OF INJURY
MM DD YYYY
WCAIS CLAIM NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth If deceased - Dependent/Guardian/Personal Representative First name
Last name
Address
Address
City/Town State ZIP
County
Telephone
INJURY INFORMATION
Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
VS. INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
AND Commonwealth of Pennsylvania Department of Labor & Industry
c/o Office of Chief Counsel 1171 South Cameron St
Harrisburg, PA 17104-2501
An employee seeking additional compensation from the Subsequent Injury fund should file this petition if the employee has previously incurred (through injury or otherwise) permanent partial disability, through the loss, or loss of use of, one hand, one arm, one foot, one leg or one eye, and incurs total disability through a subsequent injury, causing loss, or loss of use of, another hand, arm, foot, leg or eye.
1. Date of first (prior) loss or loss of use of, one hand, arm, foot, leg or eye, resulting in permanent partial disability.
- -MM DD YYYY
2. Complete description of first (prior) loss or loss of use.
a. Was this loss or loss of use work-related? Yes No If Yes, name and address of employer:
3. Date of second (subsequent) loss, or loss of use of another hand, arm, foot, leg or eye, resulting in total disability.
- -MM DD YYYY
4-25
4. Complete description of second (subsequent) loss or loss of use injury. a. Was this loss of use injury work-related? Yes No If yes, name and address of employer:
5. Is there pending workers’ compensation litigation or a previous Workers’ Compensation Judge’s decision regarding the second (subsequent) loss or loss or use injury? Yes No a. If yes, when was the claim petition filed? - -
MM DD YYYY
b. If a Workers’ Compensation Judge’s decision was rendered, what was the circulation date of the decision?
- -MM DD YYYY
c. Was there an award of benefits for a specific loss or loss of use? Yes No i. If yes, how many weeks of benefits were awarded? ii. On what date did the specific loss award commence?
- -MM DD YYYY
6. What were your wages at the time of the second (subsequent) injury? $ Hour Day or Week .
7. If you have returned to work since the second (subsequent) injury, are you earning More Same Less than you were at the time of the injury? Current earnings $ Hour Day or Week .
8. Are you entitled to receive any other benefits by reason of your increased disability, either from any state or federal fund or agency? Yes No If yes, please list.
PLEASE ENTER MY APPEARANCE FOR PETITIONER:
Attorney’s name PA Attorney ID number Firm name Address Address City/Town State ZIP Telephone
- -
Date of petition
MM DD YYYY
Attorney’s signature
Notice: This petition must be filled out as fully as possible. The original must be sent to the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. You must serve a copy on all other parties, and on the attorneys of all other parties, if the attorneys are known. A Proof of Service must be attached. A Proof of Service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if known. Questions regarding the completion of this form may be directed to the Bureau of Workers’ Compensation Claims Information Services.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*375* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-375 REV 09-13 (Page 2)
4-26
DEPARTMENT OF LABOR & INDUSTRYWORKERS’ COMPENSATION OFFICE OF ADJUDICATION
LIBC-364B REV 09-13 (Page 1)
DEFENDANT’S ANSWER TO CLAIM PETITION UNDER PENNSYLVANIA
OCCUPATIONAL DISEASE ACT
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -DATE OF INJURY
MM DD YYYY
WCAIS CLAIM NUMBER
- -
EMPLOYEE EMPLOYER
First name
Last name
Date of birth Date of deathIf deceased - Dependent/Guardian/Personal RepresentativeFirst name
Last name
Address
Address
City/Town State ZIP
County Telephone
INJURY INFORMATION
Provide the following information if Employer has acceptedliability for this injury:
Part of body injured
Nature of injury
Accident/injury description narrative
“FUND” SHALL MEAN THE UNINSURED EMPLOYERS GUARANTY FUND, SUBSEQUENT INJURY FUND, SELF-INSURANCE GUARANTY FUND OR PRE-SELF-INSURANCE GUARANTY FUND.
TO YOUR HONORABLE JUDGE:
In answer to the captioned claim, the defendant respectfully pleads as follows: (Answers must be identified by numerical order in direct response to corresponding numbered allegations asserted in the claim petition.)
Check if occupational disease
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
VS. INSURER, FUND or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
AndCommonwealth of PennsylvaniaDepartment of Labor & Industry
Harrisburg, PA 17104-2501
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(Page 2)
As a matter of further defense, the defendant states the following:
PLEASE ENTER MY APPEARANCE FOR DEFENDANT:
Attorney’s namePA Attorney ID numberFirm nameAddressAddressCity/Town State ZIP Telephone
Date filed
MM DD YYYY
Attorney’s signature Attorney’s name (typed/printed)
Defendant’s signature Defendant’s name (typed/printed)
Notice: This answer must be filled out as fully as possible. If not filing electronically, the original must be sent to the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. You must send a copy to all unrepresented parties and to the attorney of record for all parties which are represented by counsel. A Proof of Service must be attached. A Proof of Service is a signed statement by you verifying that you have sent a copy of the answer to all parties and their attorneys, if known. Answers must be filed within 20 days of the assignment in of the petition. Every fact alleged in the petition not specifically denied by this answer shall be deemed to be admitted. Questions regarding the completion of this form may be directed to the Bureau of Workers’ Compensation Claims Information Services.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228local & outside PA TTY: 717.772.4991
Email [email protected]
*364B*Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
- -
LIBC-364B REV 09-13
5-2
DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION
DEFENDANT’S ANSWER TO CLAIM PETITION UNDER
PA WORKERS’ COMPENSATION ACT
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -DATE OF INJURY WCAIS CLAIM NUMBER
EMPLOYEE
First name
Last name
Date of birth If deceased - Dependent/Guardian/Personal Representative First name
Last name
Address
Address
City/Town State ZIP
County
Telephone
INJURY INFORMATION
Provide the following information if Employer has accepted liability for this injury:
Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
- -MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
VS. INSURER, FUND or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
“FUND” SHALL MEAN THE UNINSURED EMPLOYERS GUARANTY FUND, SUBSEQUENT INJURY FUND, SELF-INSURANCE GUARANTY FUND OR PRE-SELF-INSURANCE GUARANTY FUND.
TO YOUR HONORABLE JUDGE: In answer to the captioned claim, the defendant respectfully pleads as follows: (Answer must be identified by numerical order in direct response to corresponding numbered allegations asserted in the claim petition.)
LIBC-374 REV 09-13 (Page 1) 5-3
As a matter of further defense, the defendant states the following:
PLEASE ENTER MY APPEARANCE FOR DEFENDANT:
Attorney’s name PA Attorney ID number Firm name Address Address City/Town State
Date filed
MM DD YYYY
- -
ZIP Telephone
Attorney’s signature Attorney’s name (typed/printed)
Defendant’s signature Defendant’s name (typed/printed)
Notice: This answer must be filled out as fully as possible. If not filing electronically, the original must be sent to the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. You must send a copy to all unrepresented parties, and to the attorney of record for all other parties which are represented by counsel. A Proof of Service must be attached. A Proof of Service is a signed statement signed by you verifying that you have sent a copy of the answer to all parties and their attorneys, if known. Answers must be filed within 20 days of the assignment of the petition. Every fact alleged in the petition not specifically denied by this answer shall be deemed to be admitted. Questions regarding the completion of this form may be directed to the Bureau of Workers’ Compensation Claims Information Services.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991
Email [email protected]
*374* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-374 REV 09-13 (Page 2)
5-4
DEPARTMENT OF LABOR & INDUSTRYWORKERS’ COMPENSATION OFFICE OF ADJUDICATION
LIBC-377 REV 09-13 (Page 1)
ANSWER TO PETITION TO/FOR:
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY
MM DD YYYY
WCAIS CLAIM NUMBER
EMPLOYEE EMPLOYER
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
INJURY INFORMATION
Provide the following information if Employer has accepted liability for this injury:
Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
Name
Address
Address
City/Town State ZIP
County Telephone FEIN
(if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
NAIC code or Insurer code
Insurer/TPA claim #
- - - -
VS. INSURER or THIRD PARTY ADMINISTRATOR
TO YOUR HONORABLE JUDGE:
In answer to the following petition(s):
Review medical treatment and/or billing
Modify compensation benefits
Review compensation benefits
Set aside final receipt
Terminate compensation benefits Suspend compensation benefits Reinstate compensation benefits
Penalties
Joinder of additional defendant
In the above case, the respondent respectfully pleads as follows: (Answer in numerical order in response to corresponding numbers on petitions.)
5-5
Compensation presently payable under: Notice of compensation payable
Supplemental agreement
Agreement
Award
Additional information:
WHEREFORE, the respondent requests that the petition be dismissed or in the alternative disallowed.
Notice: This answer must be filled out as fully as possible. If not filing electronically, the original must be sent to the office of the Judge to whom the case is assigned. You must send a copy to all unrepresented parties, and to the attorney of record for all other parties which are represented by counsel. A Proof of Service must be attached. A Proof of Service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if known. Answers must be filed within 20 days of the assignment of the petition. Questions regarding the completion of this form may be directed to the Bureau of Workers’ Compensation Claims Information Services.
PLEASE ENTER MY APPEARANCE FOR RESPONDENT:Attorney’s namePA Attorney ID numberFirm nameAddressAddressCity/Town State ZIP Telephone
Date filed
MM DD YYYY
Attorney’s signature Attorney’s name (typed/printed)
Respondent’s signature Respondent’s name (typed/printed)
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S.
§1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228local & outside PA TTY: 717.772.4991
Email [email protected]
*377*
- -
Auxiliary aids and services are available upon request to individuals with disabilities.Equal Opportunity Employer/Program
LIBC-377 REV 09-13 (Page 2)
5-6
department of labor & industry workers’ compensation office of adJudication
dEfEndant’s answEr tO OccuPatiOnaL disEasE cLaiM PEtitiOn sEctiOn 301(i) OnLY
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY
MM DD YYYY
WCAIS CLAIM NUMBER
- - - -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
commonwealth of Pennsylvania Vs. department of Labor & industry
Harrisburg, Pennsylvania
tO tHE HOnOraBLE wOrKErs’ cOMPEnsatiOn JudGE:
Answers must be identified by numerical order in direct response to corresponding numbered allegation on claim petition.
The answer of the defendant to the above-captioned claim petition respectfully represents:
As a further matter of defense, the defendant states the following:
Wherefore, the defendant requests that the claim petition be dismissed.
Enter my appearance for defendant (typed)
Attorney’s name Assistant counsel’s signature Bureau of Workers’ Compensation
Address
Address
I verify that the foregoing answer is true and correct upon information and belief. I understand false statements are subject to the penalties of 18 Pa.C.S. §4904, relating to unsworn falsification to authorities.
This answer should be filed direct with the office of the Workers’ Compensation Judge to whom the case is assigned. Answer must be filed within 20 days. Every allegation in the claim petition not specifically denied will be deemed to be admitted. But the failure to deny a fact so alleged shall not preclude the Workers’ Compensation Judge before whom the petition is heard from requiring of his or her own motion proof of such fact.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer information services
717.772.3702
claims information services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447
Hearing impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991
Email [email protected]
*524* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-524 REV 09-13
5-7
5-8
DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION
NOTICE OF REQUEST FOR AN INFORMAL CONFERENCE
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
WCOA USE ONLY
Informal conference judge
Was a time extension granted? Yes No
Was a resolution reached? Yes No Partial
- -Date filing received
MM DD YYYY
- -Date of conference
MM DD YYYY
(Print)
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
Pursuant to section 402.1 of the Act, the parties herewith request that the Department schedule an informal conference in the above case.
The employee will be represented by an attorney at the informal conference:
Employee counsel Last name First name
Employer counsel
Yes No
PA Attorney ID number
Adjudicating judge Last name First name PA Attorney ID number Pending petition(s):
Last name First name
Suggested informal conference judge (if agreed upon) Last name First name
Notice: This notice must be filled out as fully as possible. The original must be sent to the workers’ compensation judge (adjudicating judge) who has the assigned petition. If there is no pending petition and one is attached, then file it with the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202 Harrisburg, PA, 17102-1400. You must send a copy to all other parties, and to the attorneys of all other parties, if known. A Proof of Service must be attached. A Proof of Service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if known. Questions regarding the completion of this form may be directed to Bureau of Workers’ Compensation Claims Information Services.
COUNSEL FOR PARTY SUBMITTING REQUEST: Date of this notice
Attorney’s name
PA Attorney ID number
Firm name Attorney’s signature
Address
Address Attorney’s name (typed/printed)
City/Town State ZIP Employee/Dependent/Guardian/Personal Representative signature
Telephone Telephone
- -MM DD YYYY
LIBC-753 REV 09-13 (Page 1) 6-1
INSTRUCTIONS AND PROCEDURES
• In order to request an informal conference, you must obtain the agreement of all parties in your matter to participate in the informal conference.
• To file this form, mail original to the workers’ compensation judge (adjudicating judge) who has the assigned petition. If there is no pending petition and one is attached, then file it with the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. This form may be filed with the signature of a representative of only one party, but only with the knowledge and consent of all parties.
• The adjudicating judge is the workers’ compensation judge who has been assigned to hold hearings and issue decisions relating to a petition(s).
• The parties may suggest an informal conference judge or hearing officer, but the assignment will be made by the judge manager from the district where the claim is pending.
• The informal conference judge or hearing officer will assign a date, location and time for the informal conference to be held within 35 days of filing of the request and may request information from the parties seeking an informal conference.
• There shall be no time extension without written agreement of all the parties which shall be filed with the informal conference judge or hearing officer.
• The adjudicating judge shall not be assigned to an informal conference.
• “All communications, verbal or written, from the parties to the workers’ compensation judge or hearing officer and any information and evidence presented to the workers’ compensation judge or hearing officer during the informal conference proceedings are confidential and shall not be a part of the record of testimony.” WC Act, 402.1(b)(ii).
• “Each party may be represented, but the employer may only be represented by an attorney at the informal conference if the employee is also represented by an attorney at the informal conference.” WC Act, 402.1 (b)(iii).
• All participants at the informal conference must have authority to resolve the matter in controversy.
• The informal conference judge or hearing officer conducting the informal conference may meet separately with each of the parties during the conference and may use other reasonable means to encourage an informal resolution.
• If the parties resolve the petition(s), the party who filed the pending petition(s) must notify the adjudicating judge that the petition(s) is (are) resolved.
• The informal conference judge or hearing officer conducting the informal conference shall reduce the agreement reached to writing which will be signed by the parties. The original informal conference agreement and attached documents shall be filed with the adjudicating judge with the copy to the informal conference judge or hearing officer.
• If the informal conference does not resolve the case, it will be returned to the assigned adjudicating judge. The parties may jointly request the adjudicating judge to reassign the case to the workers’ compensation judge who conducted the informal conference if the conference was held by a workers’ compensation judge subject to WCOA approval.
• Parties may agree to pursue the Compromise and Release procedures as a result of the informal conference through the adjudicating judge, but the Compromise and Release Agreements will not be accepted at informal conferences.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*753* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-753 REV 09-13 (Page 2)
6-2
DEPARTMENT OF LABOR & INDUSTRYWORKERS’ COMPENSATION OFFICE OF ADJUDICATION
INFORMAL CONFERENCEAGREEMENT FORM
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY
MM DD YYYY
WCAIS CLAIM NUMBER
EMPLOYEE EMPLOYER
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
1. This matter is currently pending on
before Workers’ Compensation JudgeTYPE OF PETITION(S)
NAME
2. OnthepartiesfiledaNoticeofRequestforanInformalConferencepursuanttoSection
402.1 of the Pennsylvania Workers’ Compensation Act.
3. An informal conference was conducted before on
At that conference, the employee was was not represented by counsel, and the employer was was not
represented by counsel.
4. The parties have agreed upon the following matters at the informal conference:
MM DD YYYY
ADDRESS
MM DD YYYYWorkers’ Compensation Judge
LIBC-754 REV 09-13 (Page 1)
- - - -
- -
- -
6-3
If necessary, attach separate pages, each signed by all parties, to state fully the matters agreed upon at the conference. If a Notice of Compensation Payable, Agreement for Compensation, or Supplemental Agreement has/have been executed, attach suchdocument(s).CompleteallrequiredEDItransactionsinaccordancewiththeprovisionsoftheEDIImplementationGuide.
Date of this agreement
MM DD YYYY
Employee’s signature Insurer/Employer’s Agent’s signature
Employee’s name (typed/printed) Insurer/Employer’s Agent’s name (typed/printed)
Employee’s Attorney’s signature Insurer/Employer’s Attorney’s signature
Employee’s Attorney’s name (typed/printed) Insurer/Employer’s Attorney’s name (typed/printed)
AnyindividualfilingmisleadingorincompleteinformationknowinglyandwiththeintenttodefraudisinviolationofSection1102ofthePennsylvaniaWorkers’CompensationAct,77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228local & outside PA TTY: 717.772.4991
Email [email protected]
- -
*754*Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/ProgramLIBC-754 REV 09-13 (Page 2)
6-4
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION
WORKERS’ COMPENSATION MEDICAL REPORT FORM
THIS FORM IS TO BE FILED WITH THE EMPLOYER OR INSURER ACCORDING TO INSTRUCTIONS PROVIDED ON THIS FORM.
Name of employee
Name of employer
Name of insurer
WCAIS claim number Date of birth
Employee SS# XXX-XX- Date of injury Or
WC ID number
Date of report
Provider name
Provider address
Contact person Telephone
Health care providers shall complete and submit the appropriate HCFA billing form and needed documentation to the employer. If the employer is covered by an insurer, the appropriate billing form and documentation is to be sent to the insurer. The LIBC-9 form and required accompanying documentation shall be submitted within 10 days of commencing treatment and at least once a month thereafter, as long as treatment continues. If a provider does not submit the required medical reports in the prescribed format, the employer/insurer is not obligated to pay for such treatment until the required report is received by the employer/insurer.
Documentation shall include (where pertinent) claimant’s history, diagnosis, description of treatment and services rendered, physical findings and prognosis including whether or not there has been recovery enabling the claimant to return to work with or without limitations, and specific restrictions, if any, regarding return to work. Bills for follow-up visits should include progress/office notes to support the diagnosis and codes billed.
Providers may not charge for documentation supporting a claim for payment. Providers may charge their usual fee for special reports specifically requested by the employer/insurer. All patient information shall be submitted with the knowledge of the patient and must be maintained as confidential by the employer/insurer. The employer/insurer shall not be liable to pay for treatment until the required documents have been provided.
Listed on the reverse are guidelines for the completion of billing forms and submission of records.
LIBC-9 REV 09-13 (Page 1) 7-1
BILLING FORM GUIDELINES:
Requests for payment of medical bills shall be made either on the HCFA Form 1500 or the UB92 Form, or any successor forms required by HCFA/CMS. Forms must be signed or typed with the name of the provider. Name and signature (if signature is used) must match.
Cost-based providers shall submit a detailed bill including service codes and rev codes consistent with the service codes and rev codes submitted to the Bureau of Workers’ Compensation on the detailed charge master.
Until a health care provider submits bills on one of the forms specified above, employers/insurers are not required to pay for the treatment billed.
MEDICAL REPORT FORM GUIDELINES:
This form must be submitted within 10 days of initial treatment and monthly thereafter, and must be accompanied by documentation to support the billing.
Suggested supporting documentation:
Physicians — Office notes Physical/Occupational therapists — Daily treatment records/notes with physician referral Pharmacies — NCD#, amount dispensed, RX# DME vendor — Medicare/HCPC code, certificate of medical necessity Chiropractors — Treatment notes Ambulance providers — Medicare codes, notes/reports X-ray/MRI facilities — Reports Lab Facilities — Test results Anesthesia services — ASA code, base/time units, anesthesia record Hospitals — Records from area providing the service (e.g. emergency, outpatient surgery...) Inpatient hospital admissions — H&P, discharge summary, operative report (if applicable) CORFs & Rehabilitation Centers — Daily treatment notes, including physician orders Ambulatory surgery centers — Notes and reports
General for all providers: Use the most appropriate and specific HCFA/CMS coding on billing. When using miscellaneous codes, include detailed description of services.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991
Email [email protected]
*9* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-9 REV 09-13 (Page 2)
7-2
department of labor & industry bureau of workers’ compensation
dismemberment chart sec. 306(c) WOrKers’
cOmPensatiOn act as amended
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
emPLOYee
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
inJUrY inFOrmatiOn
Part of body injured
Nature of injury
Accident/injury description narrative
Marked by M.D.
Check if occupational disease
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
emPLOYer
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
insUrer or third PartY administratOr (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
(OVER)
LIBC-134 REV 09-13 (Page 1) 7-3
dismemberment chart sec. 306(c) Workers’ compensation act as amended
Distal phalange+
Middle phalange
PhalangesProximal phalange
Distal phalange+
Proximal phalange
Metacarpus
Metacarpal+
Hamate
Triquetral Capitate
Trapezoid Carpus
Trapezium+ Pisiform
Scaphold+ Lunate+
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
employer information claims information services hearing impaired email services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*134* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-134 REV 09-13 (Page 2)
7-4
department of labor & industry bureau of workers’ compensation
dismemberment chart sec. 306(c) WOrKers’
cOmPensatiOn act as amended
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
emPLOYee
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
inJUrY inFOrmatiOn
Part of body injured
Nature of injury
Accident/injury description narrative
Marked by M.D.
Check if occupational disease
DATE OF INJURY WCAIS CLAIM NUMBER
- -MM DD YYYY
emPLOYer
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
insUrer or third PartY administratOr (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
(OVER)
LIBC-134F REV 09-13 (Page 1) 7-5
dismemberment chart sec. 306(c) Workers’ compensation act as amended
The Left Foot (Dorsal surface)
Tendo Achillis
Astragalus
Cuneiform
Mid cuneiform
Extensor brevis digitorum
Extensor longus halluois
Dorsal interossei muscle
Extensor longus digitorum
1st 2nd 3rd
4th
i
ii iii
iV
V
Cuboid Scaphoid
Os Calcis
Extensor brevis digitorum
Ex. cuneiform
Peroneus brevis
Peroneus tertius
METATARSUS
FIRST PHALANX
SECOND PHALANX
THIRD PHALANX
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
employer information claims information services hearing impaired email services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*134F* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-134F REV 09-13 (Page 2)
7-6
department of labor & industry bureau of workers’ compensation
physician’s affidavit of recovery
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY WCAIS CLAIM NUMBER
- - - -MM DD YYYY
eMpLoyee eMpLoyer
This is to certify that the aforementioned employee has fully recovered from the following work injury:
which occurred on the date shown above, and is able to resume, without limitation, his/her previous occupation of
on . - -MM DD YYYY
This affidavit is based upon an examination of aforementioned employee performed by the undersigned physician on
. - -MM DD YYYY
I attest or affirm that the statements contained herein are true and correct to the best of my knowledge, information and belief.
physician
SUBSCRIBED AND SWORN TO (OR AFFIRMED) BEFORE ME THIS
DAY OF ,
First name
Last name
Signature
MM
-DD
-YYYY
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
employer information claims information services hearing impaired email services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*497*Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-497 REV 09-13
7-7
7-8
department of labor & industry bureau of workers’ compensation
application for fee review pursuant to section 306 (f.1)
PATIENT/EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY WCAIS CLAIM NUMBER
- - - -
patient/eMploYee
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
insurer or tHirD partY aDMinistrator (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone
Contact
NAIC code or Insurer code (*Required: see BWC Website for NAIC or Insurer codes)
Insurer/TPA Claim #
FEIN
eMploYer
Name
MM DD YYYY
proviDer
Name
Address
Address
City/Town State ZIP
Telephone
Federal tax ID number
MC Provider #NPI #
Specialty
Contact
proviDer representative or corresponDence aDDress (if Other than Above)
Name
Address
Address
City/Town State ZIP
Telephone
notice: Section 306(f.1)(5) of the Worker’s Compensation Act requires that the Application for Fee Review must be filed not more than 30 days following notification of a disputed treatment or 90 days following the original billing date of treatment, whichever is later.
Address
Address
City/Town State ZIP
County
Telephone FEIN
instructions:
If not filing electronically, this form must be used to request medical fee review pursuant to Section 306 (f.1)(5) of the Workers’ Compensation Act. Your application will be returned and your request for review may not be considered until all requested documentation is provided per Sections 127.252(b) and 127.253 of the Rules and Regulations.
NOTE: If not filing electronically, send the original to: Bureau of Workers’ Compensation, Medical Fee Review Section 1171 South Cameron Street, Harrisburg, PA 17104-2597
LIBC-507 REV 09-13 (Page 1) 8-1
proof of service
I hereby cerify that on MM
-DD
-YYYY
, I served copies of the Application for Fee Review and the attached
supporting documentation to Insurer/Employer
Street address
City/Town State ZIP via
First class mail, overnight mail, etc.
Provider or representative’s signature Provider or representative’s name (Typed/Printed) (Note: Request will be returned if not signed and dated)
Telephone
This is an Act 46 (firefighter cancer) claim
Is this Fee Review Request related to trauma? Yes No
Review being requested for: Amount of payment Timelines of payment Both
Paid No part/ response Denied from Date bill originally
Paid Denied part insurerDates of service submitted to carrier: From To
- - - - - -MM DD YYYY MM DD YYYY MM DD YYYY
- - - - - -MM DD YYYY MM DD YYYY MM DD YYYY
- - - - - -MM DD YYYY MM DD YYYY MM DD YYYY
- - - - - -MM DD YYYY MM DD YYYY MM DD YYYY
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*507* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-507 REV 09-13 (Page 2)
8-2
department of labor & industry bureau of workers’ compensation
instructions for completing utilization review request
Pursuant to the provisions of the Workers’ Compensation Act (Act) and 34 Pa. Code Chapter 127 Medical Cost Containment Regulations, Utilization Review (UR) of all treatment provided by a health care provider under the Act may be subject to UR at the request of an employee, employer or insurer. Persons requesting a UR must provide all information requested on the attached Utilization Review request form. Please file electronically or complete this form carefully and accurately and MAIL the original UR request along with any attachments to:
Commonwealth of Pennsylvania Department of Labor & Industry Bureau of Workers’ Compensation Medical Treatment Review Section 1171 South Cameron Street, Room 310, Harrisburg, PA 17104-2597
Copies of the original UR request along with any attachments must also be mailed or electronically submitted to all parties (the employee, all providers under review, the insurer/employer and all counsel). For any questions regarding the filing of the UR request, please contact the Medical Treatment Review Section at 717-772-1914.
The UR request must be filled out completely. All information is required. Please enter “NONE” where appropriate. Please type or print clearly.
1. Request filed on behalf of: Check the appropriate box. 2. Employee Information: Enter all requested information. 3. Attorney for employee: Enter all requested information. 4. Employer information: Enter all requested information. 5. Insurer or self-insured employer’s third party
administrator (TPA): Enter all requested information including the NAIC code or Insurer code of the insurer or self-insured employer (available at www.dli.state.pa.us).
6. Attorney for insurer/employer: Enter all requested information.
7. Provider(s) under review: Enter the full name, complete address and telephone number of all providers who rendered or will render the treatment(s) or services(s) for which you are requesting UR. Remember that when the treatment or service to be reviewed is anesthesia incident to surgical procedures, diagnostic tests, prescriptions or durable medical equipment, the request for UR must identify the provider who made the referral, ordered or prescribed the treatment or service as the provider under review.
Further, please note that you may only request review of individual providers (i.e., physician, chiropractors, etc.), and not facilities. While facilities are often “licensed” (i.e., hospitals, only the actual providers who treat patients may be reviewed. If the treatment which you wish to review constitutes a continuum of care, please identify all providers who rendered such treatment.
Finally, if multiple providers rendered treatment under the direction or supervision of a provider with greater knowledge, education or responsibility for patient care, kindly identify both the individual providers and the directing/supervising provider.
LIBC-601 REV 09-13
8. Treatment to be reviewed: Specify ONLY the treatment or health care service to be reviewed (e.g. “Facet injections lumbar spine”), and identify the start date and end date of treatment(s) which you wish to submit to UR. If the end date is indeterminate, please enter “ongoing.” If requesting a prospective review, simply state “prospective.” Do not include any other information, such as billing issues, previous URs, or other comments which may influence a reviewer. Such comments will not be forwarded to a reviewer.
9. Billing dates for retrospective review: A UR request must be filed within 30 days of the insurer/employer’s receipt of the bill and medical report relating to the treatment under review. If you have not received a bill and/or medical report for the treatment under review or if this request is filed by the employee enter “none,” otherwise, for each provider under review, enter the date upon which the insurer/employer received the bills and reports which represents the start date of treatment submitted for UR.
10. Payment pending WCJ decision: If payment for the treatment under review was withheld pending a decision on a claim or reinstatement petition, please indicate provider(s), whose payment was withheld, and enter the circulation date of the decision awarding benefits.
11. Other treating providers: If necessary on a separate sheet, enter the full name, license, specialty, complete address and valid telephone number of all other health care providers who rendered treatment or services for the work-related injury. Please do not include non-treating providers such as those who have performed independent medical examinations.
12. Act 46: Check the box if this is an Act 46 (firefighter claim). 13. Proof of service: Provide the date the UR request was
signed and mailed to all parties. If you amend or “re-file” this request, you must update the Proof of Service Date.
14. Requesting party or representative: Type or print your name, address and telephone number. You MUST sign the UR Request, or follow the online instructions to do so electronically.
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8-4
department of labor & industry bureau of workers’ compensation utilization review request
The UR Request must be filled out completely (follow instructions): ALL INFORMATION IS REQUIRED.
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY WCAIS CLAIM NUMBER
- - - -1. Filed on behalf of: Employee Insurer/Employer
2. eMPloYee
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
4. eMPloYer
Employer name
Address
Address
City/Town State ZIP
6. insurer/eMPloYer attorneY
Firm name
First name
Last name
Address
Address
City/Town State ZIP
7-10 Provider under review/treatment information Please see instructions
ProviDer 1 First name Office address CityTelephone Treatment to be reviewed:
Last name
License/Specialty State ZIP
Start/End date Bill rec’d None
WCJ Circulation date Report rec’d None
ProviDer 2 First name Office address CityTelephone Treatment to be reviewed:
Last name
License/Specialty State ZIP
Start/End date Bill rec’d None
WCJ Circulation date Report rec’d None
MM DD YYYY
3. eMPloYee attorneY
5. insurer or selF insureD tPa
NAIC code or Bureau code (Required: See BWC Website for Bureau codes)
Insurer/TPA name
Insurer claim #
Address
Address
City/Town State ZIP
Claim rep name
Firm name
First name
Last name
Address
Address
City/Town State ZIP
LIBC-601 REV 09-13 (Page 1) 8-5
ProviDer 3 First name Office address CityTelephone Treatment to be reviewed:
Last name
License/Specialty State ZIP
Start/End date Bill rec’d None
WCJ Circulation date Report rec’d None
ProviDer 4 First name Office address CityTelephone Treatment to be reviewed:
Last name
License/Specialty State ZIP
Start/End date Bill rec’d None
WCJ Circulation date Report rec’d None
ProviDer 5 First name Office address CityTelephone Treatment to be reviewed:
Last name
License/Specialty State ZIP
Start/End date Bill rec’d None
WCJ Circulation date Report rec’d None
(Pursuant to §127.404(b) the request for UR shall be filed within 30 days of receipt of the bill and report for the treatment at issue)
11. other treating Providers: If not filing electronically, please list any other treating providers for this claimant on additional sheet. Include first and last name, license and specialty, full address and telephone number for each provider.
12. This is an Act 46 (firefighter cancer) claim
13. Proof of service: I hereby certify that on this day I have mailed a copy of this request to all parties and their attorneys, if known, including the provider(s) under review. ANY FALSE STATEMENT CONTAINED IN THIS UTILIZATION REVIEW REQUEST MAY BE THE SUBJECT OF PROSECUTION UNDER ARTICLE XI OF THE ACT (RELATING TO INSURANCE FRAUD), OR 18 Pa. C.S. §4903 (RELATING TO FALSE SWEARING).
14. Requesting Party or Representative’s signature Requesting Party or Representative’s name (typed/printed)
Address City State ZIP
Telephone number Email address
Proof of Service date (MUST be updated if request is amended/re-filed)
NOTE: If not filing electronically, send the original to: Bureau of Workers’ Compensation, Medical Treatment Review Section 1171 South Cameron Street, Harrisburg, PA 17104-2597
DO NOT attach deposition, medical records, IME reports or any other document not specifically requested to the UR Request Form. Any attachments not specifically requested will NOT be forwarded to the URO, and will NOT be returned. The Bureau will destroy/shred all attachments not requested.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
employer information Claims information services Hearing impaired email services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*601* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-601 REV 09-13 (Page 2)
8-6
department of labor & industry workers’ compensation office of adjudication
petition for review of utilization review
determination
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- - - -
DATE OF INJURY WCAIS CLAIM NUMBER
MM DD YYYY
If the insurer/employer, employee or provider disagrees with the determination rendered against it by the URO, the insurer/employer, employee or provider may file this petition to request that a Workers’ Compensation Judge review the URO’s determination.
emploYee
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
utilization review number: (FROM THE UTILIZATION REVIEW DETERMINATION FACE SHEET)
URO name
Address
Address
City/Town State ZIP
emploYer
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
vS. inSurer or tHird partY adminiStrator (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Insurer/TPA claim #
This request is filed by or on behalf of Employee Insurer/Employer Health Care Provider
attorneY for inSurer/emploYee (if known) attorneY for inSurer/emploYer (if known)
Name
Firm name
Address
Address
City/Town State ZIP
Telephone PA Attorney ID number
Name
Firm name
Address
Address
City/Town State ZIP
Telephone PA Attorney ID number
LIBC-603 REV 09-13 (Page 1) 8-7
I hereby request that this petition be assigned to a Workers’ Compensation Judge for a hearing to determine the reasonableness or necessity of the treatment provided by or prescribed by the health care provider below:
provider under review attorneY for provider (if known)
First name
Last name
Address
Address
City/Town State ZIP
Name
Firm name
Address
Address
City/Town State ZIP
Telephone PA Attorney ID number
NOTE: The ‘treatment to be reviewed’ and the ‘dates of treatment’ can be obtained from the UR Request form.
Treatment to be reviewed:
- -MM DD YYYY
(NOTE: DO NOT USE PROCEDURE CODES TO IDENTIFY TREATMENT TO BE REVIEWED)
Date(s) of treatment to be reviewed:
I hereby certify that on this day I have mailed a copy of this petition to all parties and their attorneys, if known, including the provider whose treatment is under review.
Requesting Party or Representative’s signature Requesting Party or Representative’s name (typed/printed)
Date - -MM DD YYYY
NOTICE: Petition will be returned if not signed and dated. Do not attach any documents to this petition. The Workers’ Compensation Office of Adjudication will destroy all attachments and NOT forward them to the Workers’ Compensation Judge and NOT return them to you.
NOTE: This petition must be filled out as fully as possible. If not filing electronically, the original must be sent to the Workers’ Compensation Office of Adjudication, 1010 N 7th Street, Suite 202, Harrisburg, PA, 17102-1400. You must send a copy to all other parties, and on the attorneys of all other parties, if the attorneys are known. A proof of service must be attached. A proof of service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if known. Questions regarding the completion of this form may be directed to Bureau of Workers’ Compensation Claims Information Services.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*603* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-603 REV 09-13 (Page 2)
8-8
DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION
REQUEST FOR HEARING TO CONTEST FEE REVIEW
DETERMINATION
PATIENT/EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- - - -DATE OF INJURY WCAIS CLAIM NUMBER
MM DD YYYY
PROVIDER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Specialty
Contact
PATIENT/EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
EMPLOYER
Name
Address
Address
City/Town State ZIP
Telephone FEIN
THIS REQUEST IS BEING FILED BY: HEALTH CARE PROVIDER INSURER/EMPLOYER
FEE REVIEW APPLICATION NUMBER(S) AND DATE OF FEE REVIEW DETERMINATIONS(S):
Application number: Determination date:
Application number: Determination date:
Application number: Determination date:
TO THE FEE REVIEW HEARING OFFICE:
I hereby request a de novo hearing by a fee review hearing officer under 34 Pa. Code §127.257 in the above-referenced Fee Review Application(s).
a. The following bills are disputed:
BILLING FORM DATE OF BILL SERVICE DATE PROC/SVC CODE AMOUNT BILLED
LIBC-606 REV 09-13 (Page 1) 8-9
b. The following factual issues relative to the medical payment matter are in dispute. Concisely state all factual issues. Do Not attach supplemental pages.
c. The following legal issues are in dispute. Concisely cite the specific statutory and regulatory authority asserted to be relevant and/or applicable in this matter. Do Not attach supplemental pages.
Requesting Party or Representative’s signature Requesting Party or Representative’s name (typed/printed)
Telephone
PLEASE ENTER MY APPEARANCE FOR PETITIONER: COUNSEL FOR RESPONDENT (if known):
Attorney’s name Attorney’s name PA Attorney ID number PA Attorney ID number Firm name Firm name Address Address Address Address City/Town State ZIP City/Town State ZIP Telephone Telephone
Notice: This petition must be filled out as fully as possible. If not filing electronically, the original must be sent to the Workers’ Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. A copy must be sent to the prevailing party in the fee review determination that you are appealing. A Proof of Service must be attached. A Proof of Service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if known.
All requests for a hearing will be returned if not signed and dated. Do not attach documents to this request. The Workers’ Compensation Office of Adjudication will destroy all attachments and will NOT process them or return them to you.
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*606* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-606 REV 09-13 (Page 2)
8-10
American LegalNet, Inc.www.USCourtForms.com
SUBMIT APPLICATION TO:
COMMONWEALTH OF PENNSYLVANIADEPARTMENT OF LABOR AND INDUSTRYBUREAU OF WORKERS’ COMPENSATION
1171 S. CAMERON STREET, ROOM 103HARRISBURG, PA 17104-2501
EMPLOYER’S APPLICATION TOELECT DOMESTIC EMPLOYEES TOCOME WITHIN PROVISIONS OF THEWORKERS’ COMPENSATION ACT:
SECTION 321
1. Name of Employer _____________________________________________________________________________
2. Address ______________________________________ City ________________________ State ___________
3. Zip Code ____________________________ Telephone Number_____________________________________
4. List employee name, address, and social security number:
(1) Name of Employee ________________________________________ S. S. # ______________________
Address _______________________________________________________________________________
(2) Name of Employee ________________________________________ S. S. # ______________________
Address _______________________________________________________________________________
(3) Name of Employee ________________________________________ S. S. # ______________________
Address _______________________________________________________________________________
(4) Name of Employee ________________________________________ S. S. # ______________________
Address _______________________________________________________________________________
(5) Name of Employee ________________________________________ S. S. # ______________________
Address _______________________________________________________________________________
5. Employer currently has workers’ compensation coverage: Yes No
If Yes: Insurance Company _____________________________________________________________________
Policy Number __________________________________ Policy Effective Date ___________________
, the undersigned employer of the domestic employees named above, do hereby petition the Bureau of Workers’Compensation, Department of Labor and Industry, to permit me to come within the provisions of the Workers’Compensation Act of 1915 and the amendments thereto, in accordance with the provisions of Section 321, andI aver that I have been informed and fully understand that, if this application is granted, I will be bound by all of theprovisions of the Workers’ Compensation Act.
EMPLOYER’S SIGNATURE
PRINT NAME
DO NOT WRITE BELOW LINE: BUREAU USE ONLY
The application is hereby granted
CHIEF OF COMPLIANCE, BUREAU OF WORKERS’ COMPENSATION DATE
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9-2
EMPLOYER’S LIGHT DUTY RETURNTO WORK FORM
Employee Employer
Address Address
City State Zip City State Zip
Telephone Telephone
LIST OF LIGHT DUTY RESTRICTIONS (Please have the employee initial each box where a restriction is listed)
**THIS IS NOT AN ADMISSION OF A COMPENSABLE INJURY.**
The employee is specifically directed not to work beyond their medical restrictions. If the employee does work beyond the scope of his/her medical restrictions, it will be in direct violation of a “positive work order”. If the undersigned employee violates this “positive work order” to work within their medical restrictions, they may be subject to discipline up to and including termination.
**YOUR SIGNATURE IS A TESTAMENT THAT YOU HAVE READ,UNDERSTOOD AND ANY QUESTIONS THAT YOU HAD WERE ANSWERED.”
DATE EMPLOYEE
DATE EMPLOYER
DATE WITNESS
DATE WITNESS
9-3
9-4
LIBC-14 REV 09-13
INSTRUCTIONS FOR RELIGIOUSEXCEPTION APPLICATION
You can complete the application for religious exception by visiting www.dli.state.pa.us/WCAIS. You must be registered as an employer with WCAIS to submit the application online. Once you are logged in, select the option to submit Application for Religious Exception from the navigation menu.
You can also complete and return the forms enclosed. This application is to be used to request an “employee religious exception” from coverage under the Pennsylvania Workers’ Compensation Act pursuant to §304.2 of the Act. All questions must be answered.
An executed and notarized copy of Form LIBC-14B, Employee’s Affidavit and Waiver of Workers’ Compensation Benefits and Statement of Religious Sect must be uploaded with the application online or attached to enclosed application for each employee for whom exception is sought. It is necessary that the religious sect leader complete and sign a portion of the form. In the event that the employee has previously been excepted from coverage, a copy of Form LIBC-14C, Certification of Religious Exception, may be uploaded with the application online or attached to this application instead of Form LIBC-14B provided the employee continues to be a member of the same religious sect and continues to adhere to its teachings and tenets.
All employees requesting an exception who are members of the same religious sect or division may be included on one application. If you are using the enclosed forms and if additional space is required, indicate at the bottom of Question 7 and attach additional listing.
A separate application is required for each religious sect or division thereof under which employee(s) are requesting an exception to the Pennsylvania Workers’ Compensation Act.
Notification must be supplied to the Bureau of Workers’ Compensation if any of the employees who are granted such an exception cease to be qualified for that exception.
*14*
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected] 717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
DEPARTMENT OF LABOR & INDUSTRYBUREAU OF WORKERS’ COMPENSATION
Auxiliary aids and services are available upon request to individuals with disabilities.Equal Opportunity Employer/Program
9-5
9-6
bureau of workers’ compensation
section 304.2 application for religious exception of specified employees from
the provisions of the pennsylvania workers’ compensation act
1. name of employer fein#
2. address
3. employer is sole proprietor partnership corporation
4. nature of business of employer
5. (a) total number of all persons employed by this employer (b) total number of employees for whom exception is sought
6. employer’s current workers’ compensation coverage: (a) If self-insured, effective date of certificate and insurer code number(b) if covered by insurance policy:
name of insurance company name and address of insurance agent, if any
policy number policy effective date
7. (a) full name of religious sect including division thereof
(b) name and address of local leader of above religious sect
(c) Does religious sect above provide financial or otherwise, for injured or deceased members andfamilies thereof? yes no
(d) list employee member(s), address, date of birth and social security number, requesting exception under the pennsylvania workers’ compensation act. NOTE: for each employee listed, an executed copy of the “Employee’s Affidavit and Waiver of Workers’ Compensation Benefits andstatement of religious sect” must be attached to this application.
(1) name of employee s.s. # Address Date of Birth
(2) name of employee s.s. # Address Date of Birth
(3) name of employee s.s. # Address Date of Birth
(4) name of employee s.s. # Address Date of Birth
(5) name of employee s.s. # Address Date of Birth
(6) name of employee s.s. # Address Date of Birth
Note: if additional employees, check here and attach separate lists(s).
LIBC-14A REV 09-13 (Page 1) 9-7
8. List employees requesting exception who have been granted a similar exception from coverage underthe federal social security system and attach a copy of the approved internal revenue service form 4029, if available.
(1) name of employee s.s. # Address Date of Birth
(2) name of employee s.s. # Address Date of Birth
(3) name of employee s.s. # Address Date of Birth
(4) name of employee s.s. # Address Date of Birth
(5) name of employee s.s. # Address Date of Birth
(6) name of employee s.s. # Address Date of Birth
This application must be signed by the employer or, if a corporation, an officer thereof as set forth below.
employer’s signature employer’s name (typed/printed)
Officer and title Telephone
Note: If not filing electronically, send the original to: Bureau of Workers’ Compensation Compliance Section, Room 324
1171 South Cameron Street, Harrisburg, PA 17104-2597
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Services
717.772.3702
Claims Information Services toll-free inside PA: 800.482.2383local & outside pa: 717.772.4447
Hearing Impaired toll-free inside PA TTY: 800.362.4228local & outside pa tty: 717.772.4991
Email [email protected]
*14A* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-14A REV 09-13 (Page 2)
9-8
bureau of workers’ compensation
employee’s affidavit and waiver of workers’
compensation benefits and statement of religious sect
(To be filed with the §304.2 Application for Religious Exception)
employee
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
employer
Employer name
Address
Address
City/Town State ZIP
FEIN
waiver of workers’ compensation and affidavit
I, EMPLOYEE
, do hereby state and affirm that I am a member of , RELIGIOUS SECT OR DIVISION
whose established tenets and/or teachings conscientiously oppose member acceptance of any public or private insurance benefits which make payments in the even of death, disability, old age, retirement, or makes payment towards the cost of or provides services for medical bills (including the benefits of any insurance system established by the Federal Social Security Act): I adhere to said tenets and/or teachings. I am, therefore, knowingly and voluntarily waiving my rights to any benefits under the Pennsylvania Workers’ Compensation Act.
Subscribed and affirmed to before me this
day of , 20 EMPLOYEE’S SIGNATURE (or Parent or Guardian in case of minor)
NOTARY PUBLIC (SEAL)
statement of religious sect
I, , hereby state and affirm that I am the relgious leader of ,RELIGIOUS SECT LEADER RELIGIOUS SECT
and I verify that is a current member of this sect. ABOVE NAMED EMPLOYEE
I state and affirm that this religious sect has established tenets and/or teachings which oppose its members’ acceptance of any public or private insurance benefits which make payments in the even of death, disability, old age, retirement, or makes payments towards the cost of or provides services for medical bills (including the benefits of any insurance system established by the Federal Social Security Act). Furthermore, I state and affirm that it is the practice, and has been for
NUMBER OF YEARS
for members of the sect or division to make provision for their dependent members which, in its judgment, is reasonable in view of their general level of living.
RELIGIOUS SECT LEADER’S SIGNATURE TITLE
RELIGIOUS SECT LEADER’S NAME (typed/printed) DATE (MM-DD-YYYY)
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
employer information claims information services Hearing impaired email services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*14B*Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program
LIBC-14B REV 09-13 9-9
9-10
LEGAL DISCLAIMER: These instructions may change without notice based upon new case law, amendments to the Act, WC Rules, and/or BWC Regulations. Feel free to call one of the attorneys at Cipriani & Werner, P.C. using the phone numbers on the cover of this book to confirm that the law has not changed. Please note that the colored boxes on this form were added by C&W for instructional purposes only. Copies of forms acceptable to the Bureau should be obtained from the Bureau or a Bureau-approved vendor.
INFORMATION FOR EMPLOYEE ACKNOWLEDGEMENT FORMS
1. “PANEL PHYSICIANS LIST”: The DESIGNATED HEALTH CARE PROVIDERS (commonly referred to
as the “Panel Physicians list”) must be posted in the workplace.
a. The Employer may even give a copy to their employees every time they sign the NOTICE OF RIGHTS & DUTIES form.
b. If the Employer does not have a fixed workplace, have the supervisors carry extra copies of the “Panel Physicians list” to each job location.
c. On accepted cases only, Claimants are required to treat with a medical provider on the
employer’s list of DESIGNATED HEALTH CARE PROVIDERS (“Panel Physicians list”) for the first 90 days after the initial visit of treatment.
2. NOTICES: Employers must now provide their employees with two separate notices, on two different
pieces of paper, at the time of hire and the time of injury. (See §121.3b of the WC regulations.)
a. The notices are: i. NOTICE OF RIGHTS & DUTIES
and ii. WORKERS' COMPENSATION INFORMATION
b. Procedure: Have the employee sign both forms and give them a copy for their file on two
occasions:
i. Time of hire [or now if they are already employed] and
ii. Immediately after the injury Alternatively, as soon as possible under the circumstances of the injury. If
the employee’s injuries are so severe that emergency care is required, notice of the employee’s rights and duties shall be given as soon after the occurrence of the injury as is practicable.
c. The employer’s duty to inform shall be evidenced by the employee’s written
acknowledgment of having been informed of and having understood the notice of the employee’s rights and duties.
d. Any failure of the employer to provide and evidence the notification relieves the employee from any duties specified in the notice, and the employer remains liable for all treatment rendered to the employee.
e. However, an employee may not refuse to sign an acknowledgment to avoid duties specified in the notice.
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10-2
EMPLOYEE’S RIGHTS & DUTIES UNDER SECTION 306(f.1)OF THE PENNSYLVANIA WORKERS’ COMPENSATION ACT
If you are injured while at work and medical treatment is necessary, you are required to visit one of the physicians or healthcare providers on the list designated by your employer for a period of 90 days from your first visit with the physician or health care provider.
All reasonable medical treatment and supplies (e.g. medicines, prosthetics) related to the injury will be paid for by the employer provided treatment is by a designated physician or health care provider on the list during the 90 day period. Charges for treatment and supplies are specified by the ACT. You are not responsible for the payment of any charges in excess of those specified by the ACT.
During the 90 day period, you may change from one designated physician or health care provider on the list to another physician or health care provider on the list, and the treatment will be paid for by the employer.
If the designated physician or health care provider refers you to a non-designated provider, the employer will pay for the treatment by the non-designated provider.
You have the right to obtain emergency medical treatment from a non-designated physician or health care provider however,the subsequent non-emergency treatment must be by a designated physician or health care provider for the remainder of the 90 day period.
You may seek treatment or consultation from a non-designated physician or health care provider during the 90 day period however, you are responsible for the charges for this treatment during the 90 day period.
If the employer designated physician or health care provider recommends invasive surgery, you are permitted to obtain a second opinion from a non-designated physician or health care provider. Your employer will pay for the cost for this opinion. If this opinion differs from the opinion of the designated physician or health care provider and provides a specificand detailed course of treatment, you may elect to undergo this treatment. The treatment however must be provided by a designated physician or health care provider for 90 days from the date of the visit to the non-designated physician.
You have the right to seek treatment from any physician or health care provider after the 90 day period has ended, and your employer will pay for this treatment provided it is reasonable and necessary.
You have the duty to notify your employer of treatment by a non-designated physician or health care provider within five days of your visit to this physician or provider. Your employer may not be required to pay for treatment by a non-designated physician or health care provider prior to notification. The employer however shall pay for this treatment once notified unless the treatment is found to be unreasonable.
Signing this form is an acknowledgment of your rights and duties. You may not refuse to sign this acknowledgment in order to avoid your duties.
If you have any questions, please feel free to contact the Bureau of Workers’ Compensation at 1-800-482-2383 or (717) 783-5421.
I acknowledge that I have been informed of an understand the above rights and duties.
Employee Signature Date
Employer’s Representative Signature Date
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WORKERS’ COMPENSATION INFORMATION
The workers’ compensation law provides wage loss and medical benefits to employees who cannot work,or who need medical care, because of a work-related injury.
Benefits are required to be paid by our employer when self-insured, or through insurance provided by your employer. Your employer is required to post the name of the company responsible for paying workers’ compensation benefits at its primary place of business and at its sites of employment in a prominent and easily accessible place, including, without limitation, areas used for the treatment of injured employees or for the administration of first aid.
You should report immediately any injury or work-related illness to your employer.
Your benefits could be delayed or denied if you do not notify your employer immediately.
If your claim is denied by your employer, you have the right to request a hearing before a workers’compensation judge.
The Bureau of Workers’ Compensation cannot provide legal advice. However, you may contact the Bureau of Workers’ Compensation for additional general information at: Bureau of Workers’Compensation, 1171 South Cameron Street, Room 103, Harrisburg, PA 17104-2501; telephone numberwithin Pennsylvania (800) 482-2383; telephone number outside of this Commonwealth (717) 772-4447; TTY (800) 362-4228 (for hearing and speech impaired only); www.state.pa.us, PA Keyword: workers comp.
I acknowledge that I have been informed of and understand the above rights and duties.
I hereby acknowledge receipt of the “WORKERS’ COMPENSATION INFORMATION” form.
Employee Signature Date
Employer’s Representative Signature Date
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www.FormsWorkFlow.com
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DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION
NOTICE OF CLAIM AGAINST UNINSURED EMPLOYER
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY WCAIS CLAIM NUMBER
- - - -MM DD YYYY
Instructions: Please complete both sides of this form and mail to 1171 S. Cameron St., Room 103, Harrisburg, PA 17104-2501. You must also forward a copy to the Pennsylvania Uninsured Employers Guaranty Fund at P.O. Box 1774, Harrisburg, PA 17105-1774. You must complete all questions that appear in bold print or the Bureau will not accept this form and will return it to you. A Claim Petition for Benefits From the Uninsured Employer and the Uninsured Employers Guaranty Fund, Form LIBC-550, may be filed 21 days after filing this form.
EMPLOYEE EMPLOYER
First name Name
Last name Address
Date of birth Address
Address City/Town State ZIP
Address County
City/Town State ZIP Telephone FEIN
County Telephone Owner/Contact
Injury
Did the injury result in a fatality? Yes No
Where did the injury occur; Address:
City: State:
Describe the incident and injury.
Was the injury reported to the employer? Yes No If yes, when?
To whom?
Disability
Occupation/Job Title
List the employee’s weekly wages at the time of injury
Last day worked Hours worked per week - -MM DD YYYY
ATTACH MOST RECENT PAY STATEMENT OR CHECK/STUB.
Did the injury cause a loss of wages? Yes No
Has the employer been paying for lost wages? Yes No
Has the employee returned to work? Yes No If so, when?
How much is the employee earning $ per hour / day / week (circle one)
For whom does the employee work? Give name, address and telephone number
LIBC-551 REV 09-13 (Page 1) 11-3
Medical
Has the employee sought medical treatment for the work injury? Yes No
Has the employer paid for medical treatment for the work injury? Yes No
List Doctors/Medical Facilities and their addresses. (Attach additional sheets, if necessary.)
The injured employee (or dependent, if the employee is deceased) must complete and sign the following authorization, which the Uninsured Employers Guaranty Fund may use to collect records relating to medical treatment that the injured or deceased employee received, and to collect wage information from the injured or deceased employee’s current or previous employer(s).
AUTHORIZATION TO RELEASE INFORMATION/VERIFICATION OR INFORMATION
To Whom It May Concern:
By signing below, I hereby request and authorize you to furnish to the Pennsylvania Uninsured Employers Guaranty Fund or its representative(s) any and all information you have concerning the above-named employee with respect to any illness or injury, medical history, consultation, treatment, including x-rays, as well as copies of all hospital or medical records, military records or other government records.
I further request and authorize employers to furnish complete information concerning wages, commissions and the like. By signing below, I attest that I am the employee identified above, or that I am the deceased employee’s dependent authorized to request the release of such records, and that I am pursuing a claim for benefits under the Pennsylvania Workers’ Compensation Act.
A photocopy of this authorization shall be considered as effective and valid as the original authorization.
VERIFICATION
By signing below, I verify that all information submitted on this form is, to the best of my knowledge, information and belief, true, complete and correct. I understand that any individual who knowingly and with the intent to defraud, files misleading or incomplete information is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to civil and criminal penalties, including prosecutions under 18 Pa. C.S.A. §4903 (relating to false swearing).
Employee or dependent signature: Print name: Address:
Telephone: Relationship to deceased employee, if applicable:
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 [email protected]
717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991
*551* Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program LIBC-551 REV 09-13 (Page 2)
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