Pennsylvania > Workers Comp
Commutation Of Compensation LIBC-498 - Pennsylvania
| Commutation Of Compensation 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 Index No. Calendar No. COMMUTATION OF Plaintiff(s) COMPENSATION -against- Social Security Number: : Date of Injury: : : PA BWC Claim Number: JUDICIAL SUBPOENA (IF KNOWN) MM DD YYYY Employee First Name Street 1 Street 2 City/Town County Last Name Employer Name Street 1 Street 2 : : Defendant(s) : . . . . . . . . . . . . . . . . . . . . . .State . . . .Zip Code . . . . . . . . . . . . . . . City/Town. . . .. .... .... Telephone County Telephone State Zip Code THE PEOPLE OF THE STATE OF NEW YORK TO FEIN Insurer or Third Party Administrator (if self-insured) Name Street 1 GREETINGS: Street 2 City/Town State Zip attend before WE COMMAND 1297-1 that all business and excuses being laid aside, you and each of you Code 498 YOU, , the Honorable at the Court Telephone Bureau Code located at County of in room , on the day of , 20 County , 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 Claim Number FEIN A copy of this notice offailure to comply with this subpoena is punishable as a contempt offull payment of compensation to Your Commutation of Compensation is to be sent to the employee with court and will make you liable commuted,partythe original behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a and on whose filed with the Bureau. the result of your failure to comply. Pursuant to Section 412 of the Pennsylvania Workers' Compensation Act, future installments of compensation payable to the above employee not being in excess of 52 weeks, the employer/insurer indicated above hereby advises the above Witness, Honorable one of the employee of its intent to immediately pay in one sum such future installments without,discount. Justices of the Court in Compensation for this injury, County, day of , 20 NATURE OF INJURY , is presently payable under days. days. Notice of Compensation Payable or Agreement for Compensation paid to date of this notice: Compensation due in future: $ weeks weeks weeks (Attorney must sign above and type name below) days @ $ per week for a total of to be paid in one sum without discount. MM DD YYYY Attorney(s) for DATE OF THIS NOTICE: Employer First Name Signature Authorized Agent for Insurer or TPA (if self-insured) Last Name First Name Signature Last Name Office and P.O. Address Telephone No.: Facsimile No.: Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 E-Mail Address: 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. LIBC-498 REV 12-97 American LegalNet, Inc. www.USCourtForms.com
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