Pennsylvania > Workers Comp
Notice Of Suspension For Failure To Return Form LIBC-760 LIBC-762 - Pennsylvania
| Notice Of Suspension For Failure To Return Form LIBC-760 Form. This is a Pennsylvania form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
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 NOTICE OF SUSPENSION FOR FAILURE TO RETURN FORM LIBC-760 Social Security Number: : Date of Injury: PA BWC JUDICIAL Claim Number: -againstEmployee First Name Street 1 Street 2 Last Name (EMPLOYEE VERIFICATION OF Plaintiff(s) EMPLOYMENT, SELF-EMPLOYMENT OR CHANGE IN PHYSICAL CONDITION) : : : : DD YYYY SUBPOENA (IF KNOWN) Employer Name Street 1 Defendant(s) Street 2 : . . . . . . . . . . . . . . . . . . . . . . . .State . . . .Zip Code . . . . . . . . . . . . . . . City/Town. .. .... .... City/Town County Telephone County Telephone State Zip Code THE PEOPLE OF THE STATE OF NEW YORK TO FEIN Insurer or Third Party Administrator (if self-insured) Name Street 1 GREETINGS: Street 2 DATE OF THIS NOTICE: City/Town WE COMMAND YOU, that all business and excuses being laid aside, you and eachState you Zip Code before of attend 762 1297-1 , 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 MM DD YYYY FEIN Attorney for Employee (if known) Attorney for Insurer/Employer (if known) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Name 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. Firm Name Firm Name Name Street 1 Street 1 Witness, Honorable County, Street 2Court in City/Town Telephone State , one of the Justices of the day of Zip Code , 20 Street 2 City/Town Telephone State Zip Code PA Attorney ID Number PA Attorney ID Number (Attorney must sign above and type name below) Claim Representative First Name Signature Telephone Attorney(s) for Last Name Office and P.O. Address A COPY OF THIS FORM AND ATTACHMENTS ARE TO BE PROVIDED TO THE EMPLOYEE, THE EMPLOYEE'S Telephone No.: ATTORNEY (IF KNOWN), AND THE ORIGINAL MUST BE MAILED TO PENNSYLVANIA DEPARTMENT OF LABOR Facsimile No.: AND INDUSTRY, BUREAU OF WORKERS' COMPENSATION, AT THE ADDRESS SHOWN ABOVE. E-Mail Address: Mobile Tel. No.: (OVER) LIBC-762 REV 12-97 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) Index No. LIBC-762 Calendar No. You are hereby notified that your workers' compensation benefits have been suspended as of : JUDICIAL SUBPOENA MM DD YYYY due to your failure to return the Employee Verification of Employment, Self-Employment or Change in Physical Condition -against- : : form (LIBC-760) which was mailed to you on MM DD YYYY . This form was due for return to the sender within 30 calendar days of its receipt. Your failure to return the completed form within this time period entitles your insurer/employer : to suspend your workers' compensation benefits under Section 311.1(g) of the Pennsylvania Workers' Compensation Act. Defendant(s) : ...................................................... Your workers' compensation benefits will immediately begin again upon your insurer/employer's receipt of the verification form, but you will not OF THE STATE OF NEW YORK THE PEOPLE receive reinstated benefits for the period of this suspension. In addition, failure to comply with the provisions of Section 311.1(d) may subject you to prosecution under the provisions of Article XI of the Pennsylvania Workers' Compensation Act relating to fraud. TO GREETINGS: If you did return the completed LIBC-760 within the prescribed time period, contact the forms sender (insurer/employer) immediately to clarify this matter. 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 is another copy ofon the , the Employee Verification form ,to assure at you have the in the day of 20 , that o'clock opportunitynoon, and at any recessed Attached room to complete and return it or to stop thisdate, to testify and give evidence as a witness in this action on the part of the adjourned suspension action. promptly Your failure to comply with this subpoena a Petition for Reinstatement with the Pennsylvania you liable You may challenge the suspension on legal grounds by filingis punishable as a contempt of court and will makeBureau of to Workers' Compensation at the address listed on the front. Petitions can be obtained by calling the Bureau at 1-800-482-2383. 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. Witness, Honorable , one of the Justices of the Court in County, , 20 Any individual filing misleading or incompleteday of 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. (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Attachment: Employee Verification Form LIBC-760 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com
|
|||||||
