Pennsylvania Alternative Delivery of Compensation Payments

COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR AND INDUSTRY
BUREAU OF WORKERS’ COMPENSATION
1171 S. CAMERON STREET, ROOM 103
HARRISBURG, PA 17104-2501
(TOLL FREE) 800-482-2383
TTY 800-362-4228
AUTHORIZATION FOR
ALTERNATIVE DELIVERY OF
COMPENSATION PAYMENTS
Employee
Social Security Number:
Date of Injury
MM
/
DD
/
PA BWC Claim Number:
YYYY
(IF KNOWN)
Employer
Name
Name
___________________________________________________________________________
Street 1
___________________________________________________________________________
Street 1
___________________________________________________________________________
Street 2
___________________________________________________________________________
Street 2
___________________________________________________________________________
City/Town
State
Zip Code
___________________________________________________________________________
City/Town
State
Zip Code
__________________________________________
__________
County
Telephone
__________________________________________
County
_____________________________________
_________-________
(________) ________-__________________
__________
_________-_______
_________________________________
Telephone
FEIN
(______) _______-__________________
______________________________
Insurer or Third Party Administrator (if self-insured)
Name
___________________________________________________________________________
Street 1
DATE OF AUTHORIZATION
MM
/
DD
/
___________________________________________________________________________
Street 2
___________________________________________________________________________
City/Town
State
Zip Code
YYYY
__________________________________________
Telephone
__________
Bureau Code
__________-_______
(______) _______-___________________
County
______________________________
__________________________________
Claim Number
FEIN
__________________________________
______________________________
I, ____________________________________________________, hereby authorize and agree that the checks for the compensation
CLAIMANT NAME (PLEASE PRINT)
payments due to me shall be forwarded to me in the following designated manner:
c
I will pick up my checks at (please check only one box):
c
The employer/insurer will mail my checks to me at:
c
employer office
c
insurer office
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
c
The employer/insurer will direct deposit my checks to the account at the financial institution supplied on the attached
authorization for direct deposit. (Attach authorization for direct deposit provided by your financial institution.)
c
Other:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
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 NAME
CLAIMANT’S SIGNATURE
LIBC-10 REV 6-04
NAME OF EMPLOYER/INSURER REPRESENTATIVE
SIGNATURE OF EMPLOYER/INSURER REPRESENTATIVE