Pennsylvania > Workers Comp
Agreement To Stop Weekly Workers Compensation Payments (Final Receipt) LIBC-340 - Pennsylvania
| Agreement To Stop Weekly Workers Compensation Payments (Final Receipt) 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 TO STOP WEEKLY WORKERS' COMPENSATION PAYMENTS (FINAL RECEIPT) 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 Claim # FEIN State Zip NOTICE TO EMPLOYEE Signing this form means your weekly workers' compensation payments will stop. You may file a petition to reopen your claim within three years of the date to which payments were made. The signing of this form will not affect your right to receive payment for reasonable and necessary medical bills related to your injury or disease under the Workers' Compensation Act. If you have any questions regarding this form, speak with your representative or call the Bureau Helpline at 1-800-482-2383. 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. Bureau Code SIGN THIS FORM IF: Beginning and ending dates and total amount paid shown below are correct; AND You have fully recovered from your injury or disease. DO NOT SIGN THIS FORM IF: You have returned to work, but are earning less due to work related injury; OR Your employer or the insurance company is withholding your last workers' compensation check unless you sign this form. as final payment of compensation due me Received from above named INSURER the sum of $ under the Pennsylvania Workers' Compensation Act for the injury or disease incurred by me in the above case. Total amount of compensation received by me, including the final payment above, is $ covering a period of MONTH in disability benefits for wage loss MONTH DAY YEAR weeks DAY days from the date my disability began on YEAR until I was able to return to work on Date of this Agreement MONTH DAY YEAR without loss of earning power due to the injury or disease incurred by me. SIGNATURE OF EMPLOYEE NOTICE: The employer/insurance company hereby agrees that no representations have been made to claimant other than those contained in this agreement and that this complies with 34 PA. Code 121.17(a). Employer/Insurer Signature of Employer/Insurance 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-340 REV 11-97 *340 1197-1* *340 1197-1* *340 1197-1* 340 1197-1 Claims Representative Phone Number
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