Pennsylvania > Workers Comp
Employee Verification Of Employment Self-Employment Or Change In Physical Condition LIBC-760 - Pennsylvania
| Employee Verification Of Employment Self-Employment Or Change In Physical Condition Form. This is a Pennsylvania form and can be used in Workers Comp . |
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CoMMoNWeALth of PeNNSYLVANIA DePARtMeNt of LABoR & INDUStRY BUReAU of WoRKeRS' CoMPeNSAtIoN EMPLOYEE VERIFICATION OF EMPLOYMENT, SELF-EMPLOYMENT OR CHANGE IN PHYSICAL CONDITION employer Name Social Security Number _________ - _______ - _________ Date of Injury ______/_______/_________ PA BWC Claim Number _____________________________ DAte of thIS NotICe ______/_______/_________ employee first Name _________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/town County __________________________________________ State telephone (_______) _______ - _______________ Zip Code ________________________________________________ _________ ____________-_________ Last Name _____________________________________________ _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/town County ____________________________________________ telephone feIN _____________________ (_______)_______-____________________________ State Zip Code ________________________________________________ _________ ____________-_________ INSTRUCTIONS TO EMPLOYEE: Do not return this form to the Bureau of Workers' Compensation. CompleteD form must Be returneD to the party Who sent the form to you Within thirty (30) Days of your reCeipt of this form. if you Do not Complete anD return this form to the party Who sent it to you Within thirty (30) Days it may result in a suspension of your Compensation Benefits as proviDeD By seCtion 311.1(g) of the WC aCt, as Well as proseCution for frauD unDer artiCle Xi of the WC aCt. you may Be requireD to Complete anD return this form every siX (6) months. Insurer or third Party Administrator (if self-insured) Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/town telephone (_______) _______-___________________________ County ____________________________________________ Claim Number ____________________________________________ feIN _____________________ State Zip Code Bureau Code _____________________ ________________________________________________ _________ ____________-_________ instruCtions to employee: Section 311.1(d) of the Workers' Compensation Act requires employees who are receiving workers' compensation, or have filed a petition to receive workers' compensation, to verify employment, self-employment, wages and changes to physical condition. 1. Are you currently employed by any employer other than the employer listed above? Yes No 2. Are you currently self-employed? Yes No 3. Have you been employed or self-employed at any time while receiving workers' compensation benefits? Yes No LIBC-760 REV 3-07 (Page 1) (OVER) American LegalNet, Inc. www.FormsWorkflow.com 4. Has your physical condition (caused by your injury) changed? Yes No 5. Is there other information you are aware of that is relevant in determining your entitlement to, or amount of compensation? Yes No 6. Names of employers for whom you have worked since your date of injury: Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/town State Zip Code ________________________________________________ _________ ____________-_________ Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/town State Zip Code ________________________________________________ _________ ____________-_________ Period of employment: from ______/_______/_________ to ______/_______/_________ mm dd yyyy mm dd yyyy Period of employment: from ______/_______/_________ to ______/_______/_________ mm dd yyyy mm dd yyyy AMoUNt of WAgeS $ ___________ . _____ AMoUNt of WAgeS $ ___________ . _____ Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/town State Zip Code ________________________________________________ _________ ____________-_________ IF SELF-EMPLOYED From ______/_______/_________ to ______/_______/_________ mm dd yyyy mm dd yyyy AMoUNt of WAgeS $ ___________ . _____ Period of employment: from ______/_______/_________ to ______/_______/_________ mm dd yyyy mm dd yyyy AMoUNt of WAgeS $ ___________ . _____ I verify that this information is true and correct based upon my knowledge, information and belief. I understand false statements are subject to the penalties of 18 Pa. C.S. ยง4904 relating to unsworn falsification to authorities. Employee: First Name ________________________ Last Name _______________________ Signature __________________________________________________________ Date ______________________________________________________________ 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. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-760 REV 3-07 (Page 2) American LegalNet, Inc. www.FormsWorkflow.com
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