Pennsylvania > Workers Comp
Agreement For Compensation For Disability Or Permanent Injury LIBC-336 - Pennsylvania
| Agreement For Compensation For Disability Or Permanent Injury Form. This is a Pennsylvania form and can be used in Workers Comp . |
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EMPLOYEE SOCIAL SECURITY NUMBER 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 DISABILITY OR PERMANENT INJURY DATE OF INJURY MONTH DAY PA BWC CLAIM NUMBER (IF KNOWN) YEAR EMPLOYEE First Name Last Name Address Address City/Town County Telephone State Zip EMPLOYER Name Address Address City/Town County Telephone FEIN State Zip INSURER or THIRD PARTY ADMINISTRATOR (if self insured) Name Address Address City/Town Telephone County State Zip INJURY INFORMATION Body Part(s) affected Type of Injury Description of Injury Bureau Code Check if Occupational Disease Claim # FEIN NOTICE: Wage information must be completed in accordance with Section 309 of the Pennsylvania Workers' Compensation Act, and attached to this Agreement. DATE DISABILITY BEGAN NOTICE: Agreement should be clearly completed, (preferably typed) and original mailed to the Bureau at the address in the upper left corner and a copy to employee. YEAR MONTH DAY Said employer shall pay said employee compensation at a rate of $ MONTH DAY per week based on an YEAR average weekly wage of $ MONTH DAY YEAR beginning . and Date first check mailed explain below. . If the date exceeds the 21-Day Rule, check this box Payment of medical and hospital expenses are subject to the limits of time and amount provided by the Pennsylvania Workers' Compensation Act and subject to modification or termination in accordance with the Act. Compensation payable for Further matters agreed upon: We, the undersigned, agree upon the facts represented on this page as to the injuries sustained by the above named employee and their above named employer: SIGNATURE OF EMPLOYEE weeks days for loss or loss of use of under Section 306(c). SIGNATURE OF CLAIMS REPRESENTATIVE *336 1197-1* *336 1197-1* *336 336 1197-1 1197-1* DATE OF AGREEMENT Name of Claims Representative 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 and may also be subject to criminal and civil penalties through Pennsylvania Act 165. LIBC-336 REV 11-97 MONTH DAY YEAR
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