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Dismemberment Chart (Foot) LIBC-134F - Pennsylvania

Dismemberment Chart (Foot) Form. This is a Pennsylvania form and can be used in Workers Comp .
 Fillable pdf Last Modified 1/14/2014
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department of labor & industry bureau of workers' compensation dismemberment chart sec. 306(c) WOrKers' cOmPensatiOn act as amended DATE OF INJURY WCAIS CLAIM NUMBER EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER emPLOYee First name Last name Date of birth Address Address City/Town County Telephone MM DD YYYY emPLOYer Name Address Address City/Town County State ZIP Telephone FEIN State ZIP insUrer or third PartY administratOr (if self-insured) Name Address Address City/Town County Telephone Contact FEIN State ZIP inJUrY inFOrmatiOn Part of body injured Nature of injury Accident/injury description narrative Marked by Check if occupational disease M.D. NAIC code Insurer/TPA claim # or Insurer code (OVER) LIBC-134F REV 09-13 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com sec. 306(c) Workers' compensation act as amended The Left Foot (Dorsal surface) Tendo Achillis dismemberment chart Os Calcis Astragalus Extensor brevis digitorum Cuboid Scaphoid Ex. cuneiform Cuneiform Peroneus brevis Peroneus tertius Mid cuneiform le Dorsa usc l interossei m 4th 1st 2nd 3rd METATARSUS V iV i ii iii FIRST PHALANX SECOND PHALANX THIRD PHALANX Extensor brevis digitorum Extensor longus halluois Extensor longus digitorum 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 ra-li-bwc-helpline@pa.gov LIBC-134F REV 09-13 (Page 2) Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program *134F* American LegalNet, Inc. www.FormsWorkFlow.com
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