Pennsylvania Claim Petition For Workersí¢ä‰åä‹¢ Compensation

EMPLOYEE SOCIAL SECURITY NUMBER
CLAIM PETITION
FOR
WORKERS’ COMPENSATION
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
TTY 800-362-4228
-
-
DATE OF INJURY
-
-
MONTH
DAY
PA BWC CLAIM NUMBER (IF KNOWN)
YEAR
EMPLOYER
EMPLOYEE
Name
First Name
Address
Last Name
Address
If Deceased - Dependent or Guardian
City/Town
First Name
County
Last Name
Telephone (
Address
)
Zip
FEIN
VS. INSURER or THIRD PARTY ADMINISTRATOR (if self insured)
Address
Name
City/Town
Address
Zip
State
Address
County
Telephone (
State
State
City/Town
)
Telephone (
)
Zip
Bureau Code
County
FEIN
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 form LIBC-375.)
MONTH
last date of exposure
DAY
-
-
and/or
YEAR
-
.
MONTH
3. Give date of injury or onset of disease
YEAR
-
2. If occupational disease, give the last date of employment
MONTH
DAY
DAY
-
YEAR
.
-
4. How did the injury or disease happen?
5. Did injury or disease occur on employer’s premises?
Yes
No Where? (Be specific.)
MONTH
6. Notice of your injury or disease was served on your employer on
manner:
DAY
-
YEAR
-
in the following
7. What was your job title at the time of injury or disease?
362 0608
LIBC-362 REV 6-08 (Page 1)
(OVER)
8. Were you working for more than one employer at the time of your injury?
Yes
No If Yes, list additional employers:
MONTH
9. Did this problem cause you to stop working?
Yes
DAY
-
No If Yes, give date.
-
10. Are you back to work with the same employer?
Yes
11. Are you working with another employer?
No If Yes, give name and address of new employer:
Yes
No If Yes,
YEAR
12. What were your wages at the time of injury? $
Regular Job
Hour
.
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
$
More
Other Job/Give Title
Day
or Week
Same
Less
Hour
.
Day
or Week
14. I am seeking payment for (check all that apply):
Loss of Wages
MONTH
Partial disability from
DAY
MONTH
Full disability from
YEAR
MONTH
to
DAY
-
YEAR
DAY
-
-
MONTH
to
-
YEAR
DAY
-
YEAR
-
Medical bills (give name of doctor/hospital, address, type of treatment and bill in space below).
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.
15.Other ___________________________________________________________
16.Is there other pending litigation in this case?
Yes No If Yes, explain below:
PLEASE ENTER MY APPEARANCE FOR PETITIONER:
Date of Petition
Attorney Name
-
PA Attorney ID Number
MONTH
DAY
YEAR
A copy of this petition has been sent to the employer.
Firm Name
Address
Address
City/Town
Telephone (
State
Zip
Signature
Employee
Attorney
)
NOTICE: This Petition must be filled out as fully as possible. The original must be sent to
the Bureau of Workers’ Compensation, 1171 South Cameron Street, Room 103, Harrisburg,
PA 17104-2501. A copy must be sent by you to the employer. Information on the completion
of this form may be obtained by calling the Bureau of Workers’ Compensation Helpline at
800-482-2383.
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).
LIBC-362 REV 6-08 (Page 2)
Auxiliary aids and services are available
upon request to individuals with disabilities.
Equal Opportunity Employer/Program