Pennsylvania > Workers Comp
Petition For Joinder Of Additional Defendant LIBC-376 - Pennsylvania
| Petition For Joinder Of Additional Defendant 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 PETITION FOR JOINDER OF ADDITIONAL DEFENDANT 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 Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town County ____________________________________________ Telephone (_______)_______-____________________________ FEIN _____________________ State Zip Code ________________________________________________ _________ ____________-_________ VS. Insurer or Third Party Administrator (if self-insured) Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town Telephone (_______) _______-___________________________ County ____________________________________________ Claim Number ____________________________________________ FEIN _____________________ State Zip Code Bureau Code _____________________ 376 1297-1 ________________________________________________ _________ ____________-_________ Employee Employer _______________________ hereby petitions for joinder in connection with the pending _____________ petition: Additional Employer Name ___________________________________________________ Street 1 ___________________________________________________ Street 2 ___________________________________________________ City/Town State Zip Code ___________________________ ____ __________-_______ Name ___________________________________________________ Street 1 ___________________________________________________ Street 2 ___________________________________________________ City/Town State Zip Code ___________________________ ____ __________-_______ Additional Carrier Name Street 1 Attorney (if known) ___________________________________________________ ___________________________________________________ Street 2 ___________________________________________________ City/Town State Zip Code ___________________________ ____ __________-_______ Joinder is requested for the following reasons: ________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Attached are: Claim and/or other petitions All answers filed All exhibits DD YYYY The names/addresses of all parties and their counsel A statement of all hearings held or scheduled with dates Date filed: ______/______/____________ MM (OVER) LIBC-376 REV 12-97 American LegalNet, Inc. www.FormsWorkFlow.com LIBC-376 I hereby certify that a copy of this petition and exhibits were served on the employers/insurance companies as identified above with copies to counsel for parties currently on record. Petitioner First Name _________________________________ Last Name _____________________________________________ ________________________________________________________________________________ SIGNATURE Additional Employer Name ___________________________________________________ Street 1 ___________________________________________________ Street 2 ___________________________________________________ City/Town State Zip Code ___________________________ ____ __________-_______ Name Street 1 Additional Carrier Name ___________________________________________________ ___________________________________________________ Street 2 ___________________________________________________ City/Town State Zip Code ___________________________ ____ __________-_______ Street 1 Attorney (if known) ___________________________________________________ ___________________________________________________ Street 2 ___________________________________________________ City/Town State Zip Code ___________________________ ____ __________-_______ Additional Employer Name ___________________________________________________ Street 1 ___________________________________________________ Street 2 ___________________________________________________ City/Town State Zip Code ___________________________ ____ __________-_______ Name Street 1 Additional Carrier Name ___________________________________________________ ___________________________________________________ Street 2 ___________________________________________________ City/Town State Zip Code ___________________________ ____ __________-_______ Street 1 Attorney (if known) ___________________________________________________ ___________________________________________________ Street 2 ___________________________________________________ City/Town State Zip Code ___________________________ ____ __________-_______ Additional Employer Name ___________________________________________________ Street 1 ___________________________________________________ Street 2 ___________________________________________________ City/Town State Zip Code ___________________________ ____ __________-_______ Name Street 1 Additional Carrier Name ___________________________________________________ ___________________________________________________ Street 2 ___________________________________________________ City/Town State Zip Code ___________________________ ____ __________-_______ Street 1 Attorney (if known) ___________________________________________________ ___________________________________________________ Street 2 ___________________________________________________ City/Town State Zip Code _____
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