Pennsylvania > Workers Comp
Informal Conference Agreement Form LIBC-754 - Pennsylvania
| Informal Conference Agreement Form Form. This is a Pennsylvania form and can be used in Workers Comp . |
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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 INFORMAL CONFERENCE AGREEMENT FORM Social Security Number: Date of Injury: MM DD YYYY (IF KNOWN) PA BWC Claim Number: Employee First Name Street 1 Street 2 City/Town County State Telephone Zip Code Last Name Employer Name Street 1 Street 2 City/Town State Zip Code County Telephone FEIN Insurer or Third Party Administrator (if self-insured) Name Street 1 Street 2 City/Town State Zip Code Bureau Code Telephone County Claim Number FEIN 1. This matter is currently pending on TYPE OF PETITION(S) before Workers' Compensation Judge NAME ADDRESS 2. On MM DD YYYY the parties filed a Notice of Request for an Informal Conference pursuant to Section 402.1 of the Pennsylvania Workers' Compensation Act. 3. An informal conference was conducted before WORKERS' COMPENSATION JUDGE/HEARING OFFICER on MM DD YYYY . was At that conference, the employee was not represented by counsel. was was not represented by counsel, and the employer 4. The parties have agreed upon the following matters at the informal conference: INSTRUCTIONS: File the original agreement and other documents executed pursuant to this agreement in accordance with normal Bureau procedures. (OVER) LIBC-754 REV 12-97 American LegalNet, Inc. www.USCourtForms.com 2002 © American LegalNet, Inc. COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : : 5. Further matters agreed upon at the informal conference: Index No. Calendar No. LIBC-754 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 Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 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. If necessary, attach separate pages, each signed by all parties, to state fully the matters agreed upon at the conferWitness, Honorable , one of Agreement has/have ence. If a Notice of Compensation Payable, Agreement for Compensation, or Supplemental the Justices of the been Court in attach such County, executed, document(s). day of , 20 DATE OF THIS AGREEMENT: MM DD YYYY (Attorney must sign above and type name below) Employee First Name Signature Last Name Insurer/Employer Agent First Name Signature Attorney(s) for Last Name Employee Attorney (if present) First Name Office and P.O. Address Insurer/Employer Attorney (if present) First Name Signature Last Name Last Name Signature Telephone No.: Facsimile No.: E-Mail Address: 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 Mobile Tel. No.: Act 165 of 1994. American LegalNet, Inc. www.USCourtForms.com
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