Pennsylvania > Workers Comp
Agreement For Compensation For Death LIBC-338 - Pennsylvania
| Agreement For Compensation For Death Form. This is a Pennsylvania form and can be used in Workers Comp . |
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 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 AGREEMENT FOR COMPENSATION FOR DEATH Plaintiff(s) -against- Deceased's Social Security Number: Index No. : Date of Injury: Calendar No. MM DD YYYY : PA BWC Claim Number: JUDICIAL : Employer Name SUBPOENA (IF KNOWN) Deceased Employee First Name Last Name : Street 1 Date of Birth MM DD YYYY Date of Death MM DD YYYY Street 2 : State Zip Code Dependent First Name Street 1 Defendant(s)City/Town : . . . . . . . . . . . . . . .Last.Name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. County Telephone FEIN Street 2 THE PEOPLE OF THE STATE OF NEW YORK City/Town County State Zip Code Insurer or Third Party Administrator (if self-insured) Name Street 1 TO Telephone Injury Description of Injury and Cause of Death Street 2 City/Town State Zip Code GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Telephone Bureau Code , the Honorable at the Court County located at County of in room , on the day of , 20 Claim Number , at o'clock in the noon, and at any recessed FEIN Check if or adjourned date, to testify and Occupational Disease ยจ a witness in this action on the part of the give evidence as We, the following persons, dependents of the aforementioned deceased employee, and the undersigned employer, agree upon the following matters which determine dependents' rights to compensate and its amount and duration: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to NAME RESIDENCE RELATIONSHIP the party on whose behalf this subpoena was issued for a maximum penalty of DATE and all damages sustained as a $50 OF BIRTH (MM/DD/YYYY) result of your failure to comply. , one of the Justices of the day of , 20 Witness, Honorable Court in County, (Attorney must sign above and type name below) Compensation was paid for the deceased employee's disability resulting Attorney(s) for beginning from said injury . and ending MM DD YYYY MM DD YYYY Wage information must be completed in accordance with Section 309 of the Pennsylvania Workers' Compensation Act, and attached to this Agreement. In case of a change in the status of any dependent, this agreement shall be modified by Supplemental Agreement or order of a Workers' Compensation Judge in accordance with the Pennsylvania Workers' Compensation Act. (OVER) LIBC-338 REV 12-97 Office and P.O. Address Telephone No.: 338 Facsimile No.: 1297-1 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) Index No. LIBC-338 Calendar No. , is as The compensation payable under the agreed facts, based on the average weekly wage of $ : follows: JUDICIAL WEEKLY RATE FROM (MM/DD/YYYY) SUBPOENA AMOUNT $ TO # WEEKS/# DAYS REASON FOR CHANGE -against- (MM/DD/YYYY) : : $ $ $ : $ $ $ Defendant(s) : ...................................................... $ $ $ $ THE PEOPLE OF THE STATE OF NEW YORK TO Amount expended for medical $ Amount expended for burial $ $ $ $ Further matters agreed upon: GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, MM , one of the Justices of the Last Name DATE OF THIS AGREEMENT: DD day YYYY of , 20 First Name Signature Employer (Attorney must sign above and type name below) Dependent First Name Signature Last Name Authorized Agent for Insurer or TPA (if self-insured) First Name Signature Attorney(s) for Last Name Office and P.O. Address NOTICE: Agreement should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left corner on the front. A copy must be sent to the dependent. Telephone No.: Facsimile No.: Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section E-Mail Address: 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Mobile Tel. No.: Pennsylvania Act 165 of 1994. American LegalNet, Inc. www.USCourtForms.com
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