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Form

Description

Quick_Reference.pdf Quick Reference for Implementation to WCAIS Forms
libc-9.pdf Medical Report Form
libc-10.pdf Authorization for Alternative Delivery of Compensation Payments
libc-14.pdf Instructions for Religious Exception Application
libc-14a.pdf Application for Religious Exception of Specified Employees from the Provisions of the Pennsylvania Workers' Compensation Act
libc-14b.pdf Employee's Affidavit and Waiver of Workers' Compensation Benefits and Statement of Religious Sect
libc-34.pdf Petition for Commutation
libc-35.pdf Answer to Petition for Commutation
libc-112.pdf WC Hearing - Interested Party Update Request Instructions
libc-113.pdf WC Hearing - Interested Party Update Request
libc-90.pdf Electronic Data Interchange First Report of Injury (A First Report of Injury (FROI) electronic data interchange or Web portal transaction is required to establish a claim in the Workers' Compensation Automation and Integration System, or WCAIS.)
libc-91.pdf Electronic Data Interchange Subsequent Report of Injury
libc-100.pdf Workers' Compensation and the Injured Worker
libc-100esp.pdf Workers' Compensation and the Injured Worker (Spanish)
libc-134.pdf Dismemberment Chart - Hand
libc-134f.pdf Dismemberment Chart - Foot
libc-336.pdf Agreement for Compensation for Disability or Permanent Injury
libc-337.pdf Supplemental Agreement for Compensation for Disability or Permanent Injury
libc-338.pdf Agreement for Compensation for Death
libc-339.pdf Supplemental Agreement for Compensation for Death
libc-340.pdf Agreement to Stop Weekly Compensation Benefits
libc-350.pdf Group Self-Insurance Fund Member Annual Contribution Worksheet Form
libc-351.pdf Expense Loss Cost Multiplier Worksheet for Group Self-Insurance Fund - Worksheet and Instructions
libc-352.pdf Expense Loss Cost Multiplier Worksheet for Group Self-Insurance Fund Deviating From Rating Organization Loss Costs Multiplier Calculation Worksheet and Instructions
libc-362.pdf Claim Petition
libc-363.pdf Fatal Claim Petition
libc-364b.pdf Defendant's Answer to Claim Petition Under Pennsylvania Workers Compensation Occupational disease Act
libc-374.pdf Defendant's Answer to Claim under Workers' Comp. Act
libc-375.pdf Claim Petition for Additional Compensation From the Subsequent Injury Fund
libc-376.pdf Petition For Joinder of Additional Defendant
libc-377.pdf Answer to Petition To:
libc-378.pdf Petition to:
libc-380.pdf Third Party Settlement Agreement (2 pages)
libc-384.pdf Fatal Claim Petition for Compensation by Dependents for Death Covered by the Pennsylvania Occupational Disease Act
libc-386.pdf Fatal Claim Petition for Compensation by Dependents For Death Resulting From Occupational Disease
libc-387.pdf Important Information about the Petition Filing and Hearing Process
libc-392a.pdf Final Statement of Account of Compensation Paid
libc-396.pdf Occupational Disease Claim Petition (under section 301(1) only)
libc-480.pdf Subpoena
libc-494A.pdf Statement of Wages
libc-494C.pdf Statement of Wages (for injuries occurring on or after June 24, 1996)
libc-495.pdf Notice of Compensation Payable (NCP) (Must be filed via EDI)
libc-496.pdf Notice of Workers Compensation Denial (NCD) (Must be filed via EDI)
libc-497.pdf Physicians Affidavit of Recovery
libc-498.pdf Commutation of Compensation
libc-499.pdf Petition for Physical Examination or Expert Interview of Employee
libc-500.pdf POSTER -Insurance Posting Form
libc-501.pdf Notice of Temporary Compensation (Must be filed via EDI)
libc-502.pdf Notice Stopping Temporary Compensation (Must be filed via EDI)
libc-507.pdf Application for Fee Review Pursuant to Section 306 (F.1)
libc-509.pdf Application for Executive Officer's Declaration
libc-513.pdf Executive Officer's Declaration
libc-524.pdf Defendant's Answer to Occupational Disease Claim
libc-550.pdf Claim Petition for Benefits from the Uninsured Employer Guaranty Fund and Uninsured Employer
libc-551.pdf Notice of Claim Against Uninsured Employer
libc-601_Instructions.pdf Instructions For Completing Utilization Review Request
libc-601.pdf Utilization Review Request
libc-603.pdf Review of Utilization Review Determination
libc-604.pdf Utilization Review Determination Face Sheet
libc-606.pdf Request For Hearing To Contest Fee Review Determination
libc-749.pdf Death Claim Supplement to Compromise And Release Agreement
libc-750.pdf Employee Report of Wages and Physical Condition
libc-751.pdf Notice of Suspension or Modification
libc-753.pdf Notice of Request for an Informal Conference
libc-754.pdf Informal Conference Agreement Form
libc-755.pdf Compromise and Release Agreement
libc-756.pdf Employees Report of Benefits
libc-757.pdf Notice of Ability to Return to Work
libc-758.pdf Notice to Claimant
libc-760.pdf Employee Verification of Employment, Self-Employment or Change in Physical Condition
libc-761.pdf Notice of Workers Compensation Offset
libc-762.pdf Notice of Suspension for Fail to Return Form LIBC-760
libc-763.pdf Notice of Reinstatement of Workers Compensation Benefits
libc-764.pdf Notice of Change of Workers Compensation Disability Benefits
libc-765.pdf Impairment Rating Evaluation Appointment
libc-766.pdf Request for Designation of a Physician to Perform an Impairment Rating Evaluation
libc-767.pdf Impairment Rating Determination Face Sheet
med_treatment.pdf Medical Treatment for Your Work Injury or Occupational Illness
Employee_rights_duties.pdf Employee Rights and Duties form - NOT A STATE FORM
Sample_Workers_Comp_Information.pdf Workers Compensation Information form - NOT A STATE FORM
libc-221i.pdf Self-Insured Employer's Initial Report of Accident and Illness Prevention Program
libc-230g.pdf Annual Report of Accident and Illness Prevention Program Status by Group Self-Insurance Funds
libc-231g.pdf Initial Report of Accident & Illness Prevention Program Status by New Group Self-Insurance Funds
libc-365.pdf Supplemental Information Addendum to Group Self-Insurance Fund Annual Report
libc-368.pdf Supplemental Information Addendum to Application for Membership in a Group Workers' Compensation Fund
libc-369.pdf Supplemental Information Addendum to Application as a Group Workers' Compensation Fund
libc-371.pdf Supplemental Information Addendum to Annual Report of Runoff Group Self-Insurance Fund