Pennsylvania > Workers Comp
Defendants Answer To Claim Petition Under Pennsylvania Occupational Disease Act LIBC-364B - Pennsylvania
| Defendants Answer To Claim Petition Under Pennsylvania Occupational Disease Act Form. This is a Pennsylvania form and can be used in Workers Comp . |
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COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. DEFENDANT'S ANSWER COMMONWEALTH OF PENNSYLVANIA Social Security Number: DEPARTMENT OF LABOR AND INDUSTRY : TO CLAIM PETITION Calendar No. BUREAU OF WORKERS' COMPENSATION Date of Injury: UNDER PENNSYLVANIA 1171 S. CAMERON STREET, ROOM 103 MM DD YYYY HARRISBURG, PA 17104-2501 OCCUPATIONAL : (TOLL FREE) 800-482-2383 PA BWC Claim Number: SUBPOENA JUDICIAL Plaintiff(s) DISEASE ACT (IF KNOWN) -against: Employee Employer First Name Street 1 Street 2 City/Town County Last Name Name Street 1 Street 2 : : State Zip Code Defendant(s) City/Town: State Zip Code ...................................................... Telephone County Telephone FEIN THE PEOPLE OF THE STATE OF NEW YORK VS. TO Insurer or Third Party Administrator (if self-insured) Name Street 1 GREETINGS: Street 2 City/Town WE COMMAND YOU, that all business and excuses being laid aside, you and eachState you Zip Code before of attend , 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 And Commonwealth and will make Your failure to comply with this subpoena is punishable as a contempt of courtof Pennsylvania you liable to Department of Labor and Industry the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Harrisburg, Pennsylvania 17104-2501 result of your failure to comply. TO YOUR HONORABLEHonorable Witness, JUDGE: , one of the Justices of the Court in County, day of , 20 In answer to the captioned claim, the Defendant respectfully pleads as follows: (Answers must be identified by numerical order in direct response to corresponding numbered allegations on claim petition.) (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: NOTICE: This answer should be clearly completed (preferably typed) and original No.: to the office of the Judge to whom Facsimile mailed the case is assigned. Answers must be filed within 20 days. Every fact alleged in the claim petition not specifically denied E-Mail Address: by this answer shall be deemed to be admitted. Mobile Tel. No.: (OVER) LlBC-364B REV 12-97 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : As a matter of further defense, the Defendant states the following: Index No. LIBC-364B Calendar No. Plaintiff(s) -against- : : : : JUDICIAL SUBPOENA Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO 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 WHEREFORE, the whose behalf this subpoena claimissued for adismissed orpenaltyalternative disallowed. the party on Defendant requests that the was petition be maximum in the of $50 and all damages sustained as a Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to result of your failure to comply. Witness, Honorable Court in County, Defendant First Name Signature Last Name , one of the Justices of the day of , 20 PLEASE ENTER MY APPEARANCE FOR DEFENDANT: Attorney First Name Firm Name Last Name (Attorney must sign above and type name below) Date: MM DD YYYY Street 1 Attorney(s) for Street 2 Attorney Signature City/Town State Zip Code Date: MM DD YYYY Telephone Office and P.O. Address PA Attorney ID Number Telephone No.: Facsimile No.: 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 mayE-Mail Address: criminal and civil penalties also be subject to through Pennsylvania Act 165 of 1994. Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com
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