Pennsylvania > Workers Comp
Notice Of Request For An Informal Conference LIBC-753 - Pennsylvania
| Notice Of Request For An Informal Conference 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) 800482-2383 Index No. Calendar No. MM DD NOTICE OF REQUEST FOR AN INFORMAL CONFERENCE Plaintiff(s) -againstName Social Security Number: : : Date of Injury: PA BWC Claim Number: JUDICIAL SUBPOENA YYYY (IF KNOWN) Employee First Name Street 1 Street 2 Last Name : Employer : Street 1 Street 2 : State Zip Code City/Town County Defendant(s) City/Town: ...................................................... State Zip Code Telephone County VS. Telephone FEIN THE PEOPLE OF THE STATE OF NEW YORK BUREAU USE ONLY Date Filing Received: TO MM DD YYYY Insurer or Third Party Administrator (if self-insured) Name Date of Conference: MM DD YYYY Informal Conference Officer: Street 1 (Print) Street 2 GREETINGS: Was a Time Extension Granted? No WE COMMAND YOU, that all business and excuses being laid aside, you and eachState youZip Code before of attend City/Town Was a Resolution Reached? Yes No Partial Yes , 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 Pursuant to Section 402.1 of the comply with parties herewith request that theaDepartment schedule an informal conferYour failure to Act, the part this subpoena is punishable as contempt of court and will make you liable to ence in the above case. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Yes No PA Attorney ID Number Last Name First Name The claimant willyour failure to comply. result of be represented by an attorney at the informal conference: Employee Counsel Employer Counsel Witness, Honorable Last Name Court in County, , one of the Justices of the day of First Name , 20 PA Attorney ID Number Pending Petition(s): Workers' Compensation Adjudication Judge Suggested Informal Conference Judge/ Hearing Officer (IF AGREED UPON) (Attorney must sign above and type name below) Attorney(s) for CERTIFICATION I certify that all parties agree to this Request and all information contained in the Request is true and correct. I hereby certify that on MM DD YYYY , a copy of this Notice of Request for an Informal Conference was served upon Office and P.O. Address all parties and the Workers' Compensation Adjudicating Judge in a manner consistent with 34 Pa.Code Section 131.11(b). This certification is subject to penalties for unsworn falsification to public authorities pursuant to 18 Pa. C.S. § 4904. Telephone No.: Facsimile PARTY SUBMITTING REQUEST (Print) No.: E-Mail Address: NOTICE: File original of this Notice with the assigned Workers' Mobile Tel. No.: Compensation Adjudicating Judge. SIGNATURE (OVER) LIBC-753 REV 12-97 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. LIBC-753 : Calendar No. INSTRUCTIONS AND PROCEDURES · · : In order to request an informal conference, you must obtain the agreement of all parties in your matter to participate in JUDICIAL SUBPOENA Plaintiff(s) the informal conference. To file this form, mail original to the workers' compensation judge (adjudicating judge) who has the assigned petition. If there is no pending petition and one is attached, then file it with the Department of Labor and Industry, Bureau of : Workers' Compensation, 1171 South Cameron Street, Room 103, Harrisburg, PA 17104-2501. This form may be filed with the signature of a representative of only one party, but only with the knowledge and consent of all parties. -against- : : · · · Defendant(s) The "adjudicating judge" is the workers' compensation judge who has: been assigned to resolve the formal petition. ...................................................... The parties may suggest an informal conference judge/hearing officer, but the assignment will be made by the judge manager from the district where the claim is pending. THE PEOPLE OF THE STATE OF NEW YORK The informal conference judge or hearing officer will assign a date, location and time for the informal conference to be held within 35 days of filing of the request and may request information from the parties seeking an informal conference. TO There shall be no time extension without written agreement of all the parties which shall be filed with the informal conference judge or hearing officer. · · · GREETINGS: The adjudicating judge shall not be assigned to an informal conference. All communications, verbal or written, from the parties to the workers' compensation judge or hearing officer and any , the Honorable at the Court information and evidence presented to the workers' compensation judge or hearing officer during the informal conference located at County of proceedings are confidential and shall not be a part of the record of testimony." WC Act, 402.1(b)(ii). WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 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 · · · Each party may be represented, but the employer may only be represented by an attorney at the informal conference if the employee is also represented by an attorney at the informal conference.," WC Act, 402.1(b)(iii). All participants atfailure to comply with this subpoena is punishable as a the matter of court and will make you liable to Your the informal conference must have authority to resolve contempt in controversy. The informal conference judge or hearing officer conducting the informal conference may meet separately with each of result of your failure to comply. the parties during the conference and may use other reasonable means to encourage an informal resolution. If the parties resolve the petition(s), the party who filed the pending petition(s) must notify the adjudicating judge Court petition(s) is(are) resolved. County, day of , 20 that the in The informal conference judge or hearing officer conducting the informal conference shall reduce the agreement reached to writin
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