Pennsylvania > Workers Comp
Notice Of Reinstatement Of Workers Compensation Benefits LIBC-763 - Pennsylvania
| Notice Of Reinstatement Of Workers Compensation Benefits 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 NOTICE OF Social Security Number: REINSTATEMENT OF WORKERS' Date of Injury: MM DD COURT COMPENSATION PA BWC Claim Number: COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . BENEFITS. . . . . . . . . . . . . . . . . . . ............ : : : : Index No. Calendar No. YYYY (IF KNOWN) Employee First Name Street 1 Street 2 City/Town County State Telephone Last Name Employer Name Street 1 Plaintiff(s) -againstZip Code Street 2 City/Town JUDICIAL SUBPOENA State Zip Code : County Telephone : FEIN Defendant(s) : ...................................................... Insurer or Third Party Administrator (if self-insured) Name Street 1 Street 2 THE PEOPLE OF THE STATE OF NEW YORK TO City/Town State Zip Code Bureau Code 763 1297-1 Telephone County GREETINGS: Claim Number FEIN DATE OF THIS NOTICE: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before MM DD YYYY , the Honorable at the Court located at County of Attorney for Employee (if known) , on the in room day of ,Attorneyat Insurer/Employer (if known) and at any recessed 20 , for o'clock in the noon, or adjourned date, to testify and give evidence as a witness in this action on the part of the Name Name Firm Name Street 1 Street 2 City/Town Telephone Firm Name Street 1 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 issuedStreet 2a maximum penalty of $50 and all damages sustained as a for result of your failure to comply. State Zip Code City/Town Telephone State Zip Code Court in Witness, Attorney ID Number Honorable PA County, , one of the Justices ID Number PA Attorney of the day of , 20 A COPY OF THIS FORM IS TO BE PROVIDED TO THE EMPLOYEE, THE EMPLOYEE'S ATTORNEY (IF KNOWN), AND THE ORIGINAL MUST BE MAILED TO BUREAU OF WORKERS' COMPENSATION AT THE ADDRESS SHOWN ABOVE. Claim Representative First Name Signature Telephone (Attorney must sign above and type name below) Last Name Attorney(s) for ¨ You are hereby notified that your workers' compensation benefits are reinstated as of MM DD YYYY , the date ¨ your Employee Verification of Employment, Self-Employment or Change in Physical Condition (LIBC-760) was or change in physical received, which indicated NO changes of employment, self-employment Office and P.O. Addresscondition. - OR You are hereby notified that your workers' compensation benefits are resumed as of , the date MM DD YYYY your completed LIBC-760 form was received. A benefit offset will occur asTelephone on the attached indicated No.: Workers' Compensation Benefit Offset (LIBC-761). Facsimile No.: Notice of Any individual filing misleading or incomplete information knowingly and with intentE-Mail Address:violation of Section 1102 of the to defraud is in Pennsylvania Workers' Compensation Act and may also be subject to criminal andMobile Tel. No.: civil penalties through Pennsylvania Act 165 of 1994. LIBC-763 REV 12-97 American LegalNet, Inc. www.USCourtForms.com
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