Pennsylvania > Workers Comp
Employee Report Of Wages And Physical Condition LIBC-750 - Pennsylvania
| Employee Report Of Wages And Physical Condition 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. MM EMPLOYEE REPORT OF WAGES AND PHYSICAL CONDITION Plaintiff(s) -against- Social Security Number: : : : Date of Injury: JUDICIAL PA BWC Claim Number: Employer DD SUBPOENA (IF KNOWN) YYYY Employee First Name Street 1 Street 2 Last Name Name Street Street 2 : : Defendant(s) : . .. . .. City/Town . . . . . . . . . . . . . . . . . . . . . . State. . . . Zip.Code . . . . . . . . . . . . . . . . . . . . . City/Town County Telephone County Telephone State Zip Code THE PEOPLE OF THE STATE OF NEW YORK TO FAILURE TO COMPLETE THIS FORM MAY SUBJECT YOU TO ARTICLE XI OF THE WC ACT RELATING TO FRAUD. FEIN Insurer or Third Party Administrator (if self-insured) Name Street 1 Street 2 GREETINGS: City/Town State WE COMMAND YOU, that FORM attend YOU MUST COMPLETE AND RETURN THISall business and excuses being laid aside, you and each of youZip Code before WITHIN THIRTY (30) DAYS OF BEGINNING EMPLOY- at the Telephone , the Honorable Court Bureau Code MENT OR SELF-EMPLOYMENT. 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 Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Yes No 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. Yes 2. Are you now self-employed? No 1. Are you now employed? 3. Have you been employed or self-employed at any time while receiving workers' compensation Justices of the Witness, Honorable , one of the benefits? No Yes Court in County, day please complete20 following: , the If you answered Yes to one of the questions, of Occupation(s) : 4. Has your physical condition (caused by your work injury) changed? (Attorney must sign above and type name below) Yes No If Yes, attach medical report. 5. Is there any other information you are aware of that is relevant in determining your entitlement to, or amount of Attorney(s) for compensation? Yes No If Yes, please explain: Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: (OVER) LIBC-750 REV 12-97 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 6. Name Streets 1 Street 2 City/Town Period of Employment: State Zip Code Index No. LIBC-750 Calendar No. Names of Employers for whom you have worked since your date of injury: Plaintiff(s) -against- : : : : Name Street 1 Street 2 City/Town JUDICIAL SUBPOENA State Zip Code Period of Employment: From Defendant(s) : . . . . . . . . . . . . . .To . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . From. . . . . .. MM DD YYYY MM DD YYYY MM DD YYYY To MM DD YYYY Amount of Wages $ Amount of wages $ Name Street 1 THE PEOPLE OF THE STATE OF NEW YORK TO IF SELF-EMPLOYED From MM DD YYYY To MM DD YYYY Street 2 City/Town Period of Employment: State Zip Code Amount of Wages $ GREETINGS: DD To WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before MM DD YYYY YYYY , the Honorable at the Court Amount of Wages $ located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed I verify or adjourned date, to testify and give evidence as amy knowledge, informationthe part of the that this information is true and correct based upon witness in this action on and belief. I understand false From MM statements are subject to the penalties of 18 Pa. C.S. ยง4904 relating to unsworn falsification to authorities. Employee Last Name Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to DATE OF THIS NOTICE: the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all DD damages sustained as a MM YYYY Signature result of your failure to comply. First Name Section 311.1(A) of the Workers' Compensation Act requires employees who are receiving workers' compensation, or who Court in County, day of , 20 have filed a petition to receive workers' compensation, to report earnings from employment or self-employment. You must complete and return this form to the sender within thirty (30) days of beginning such employment or self-employment. (Attorney must sign above and type name below) Witness, Honorable , one of the Justices of the EMPLOYEE IS TO RETURN THIS COMPLETED FORM TO THE INSURER OR THIRD PARTY ADMINISTRATOR SHOWN ON THE FRONT. Attorney(s) for 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 of 1994. Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com
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