Pennsylvania > Workers Comp
Notice Of Workers Compensation Benefit Offset LIBC-761 - Pennsylvania
| Notice Of Workers Compensation Benefit Offset 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 TTY 800-362-4228 NOTICE OF WORKERS' COMPENSATION BENEFIT OFFSET Name Social Security Number: Date of Injury: MM DD YYYY PA BWC Claim Number: (IF KNOWN) Employee First Name Street 1 Street 2 City/Town County State Telephone Zip Code Last Name Employer Street 1 Street 2 City/Town County Telephone FEIN State Zip Code Insurer or Third Party Administrator (if self-insured) Name Street 1 Street 2 City/Town Telephone County MM DD YYYY State Zip Code Bureau Code DATE OF THIS NOTICE: Claim Number FEIN Attorney for Employee (if known) Name Firm Name Street 1 Street 2 City/Town Telephone State Zip Code Attorney for Insurer/Employer (if known) Name Firm Name Street 1 Street 2 City/Town Telephone State Zip Code PA Attorney ID Number PA Attorney ID Number Claim Representative First Name Signature Telephone Last Name A COPY OF THIS FORM AND ATTACHMENTS ARE TO BE PROVIDED TO THE EMPLOYEE, THE EMPLOYEE'S ATTORNEY (IF KNOWN), AND THE ORIGINAL MUST BE MAILED TO PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY, BUREAU OF WORKERS' COMPENSATION, AT THE ADDRESS SHOWN ABOVE. (OVER) Ll BC-761 REV 8-01 American LegalNet, Inc. www.USCourtForms.com LIBC-761 You are hereby notified that the workers' compensation insurance carrier/employer (specified previously) is taking a credit that will offset your workers' compensation wage-loss benefits as authorized by Section 204 of the Pennsylvania Workers' Compensation Act. If you pay federal, state, or local taxes on an offset amount, provide a written statement to your employer/insurer showing the amount of the taxes you paid on the offset to receive reimbursement for these taxes. You may file for this reimbursement after the end of the calendar tax year. Your offset is for the following: Old Age Social Security benefits which you began to receive following an injury which occurred on or after June 24, 1996. (This offset is for one-half or 50% of this Social Security benefit.) Unemployment compensation benefits. If you are eventually found to be ineligible for the unemployment compensation payment, you must notify the above insurer/employer which shall reinstate the offset workers' compensation benefits. . Pension benefits to the extent funded by the employer directly liable for the payment of your workers' compensation benefits due to an injury occurring on or after June 24, 1996. This employer can also take credit for investment income which is attributable to this contribution. Severance benefits paid by the employer directly liable for compensation and received subsequent to a workrelated injury occurring on or after June 24, 1996. Your current workers' compensation wage-loss benefit is $ paid: Weekly Bi-Weekly . . Other (specify): will be deducted from this amount beginning on: workers' compensation benefit payments. MM DD YYYY . The offset credit of $ your receiving $ An ending date of amount of $ resulting in benefits you received. After that date you will continue to receive reduced workers' compensation benefits in the . per payment based on your continuing receipt of offsettable benefits. MM DD YYYY has been established for this offset or a portion of it to recoup prior offsetable An ending date cannot yet be established for this offset due to the continuing nature of your benefits which are applicable to an offset. You will receive an additional notice if a change occurs in this offset. This form is to provide you with at least twenty (20) calendar day's notice of this offset prior to a change in your workers' compensation benefits. The offset was calculated as follows and additional calculations may be attached: Attached are the following documents supporting the basis for this offset: You may challenge this offset by filing a Petition to Review Compensation Benefit Offset with the Pennsylvania Department of Labor and Industry, Bureau of Workers' Compensation. Petitions can be obtained by calling the Bureau at 1-800-482-2383. 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. American LegalNet, Inc. www.USCourtForms.com
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