Pennsylvania > Workers Comp
Supplemental Agreement Form Compensation For Death LIBC-339 - Pennsylvania
| Supplemental Agreement Form Compensation For Death 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. -againstDeceased Employee First Name Last Name SUPPLEMENTAL AGREEMENT FOR COMPENSATION Plaintiff(s) FOR DEATH Name Deceased's : Social Security Number: Calendar No. Date of Injury: : : PA BWC Claim Number: MM DD YYYY JUDICIAL SUBPOENA (IF KNOWN) Employer : : State Zip Code Street 1 Date of Birth MM DD YYYY Date of Death MM DD YYYY Defendant(s) : Dependent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City/Town . ..... ..... First Name Street 1 Street 2 Last Name County Telephone Street 2 THE PEOPLE OF THE STATE OF NEW YORK State Telephone Zip Code FEIN City/Town TO County Insurer or Third Party Administrator (if self-insured) Name Street 1 GREETINGS: Street 2 City/Town State Zip Code WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Telephone Bureau Code 339 1297-1 , the Honorable at the Court County located at County of FEIN in room , on the day of , 20 ,Claim Number o'clock in the at noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the We, the dependent(s) of the deceased employee and the undersigned employer, are parties to a compensation agreement or award which is changed because on , 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 issued for a maximum penalty of $50 and all damages sustained as a died result of your failure to comply. remarried the Dependent, MM DD YYYY Witness, Honorable Court in County, day of , It is now agreed that compensation shall be payable as follows: 20 WEEKLY RATE FROM (MM/DD/YYYY) $ a posthumous child was born other , one of the Justices of the AMOUNT TO (MM/DD/YYYY) # WEEKS/# DAYS REASON FOR CHANGE (Attorney must sign above and type name below) $ $ $ $ Attorney(s) for $ $ $ $ $ Office and P.O. Address $ $ $ $ The above compensation shall be payable from MM DD YYYY Telephone No.: Facsimile No.: to MM YYYY E-Mail DD Address: Mobile Tel. No.: . (OVER) LIBC-339 REV 12-97 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Further matters agreed upon: Index No. LIBC-339 Calendar No. Plaintiff(s) -against- : : : : JUDICIAL SUBPOENA Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: 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 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 DATE OF THIS AGREEMENT: MM DD YYYY Employer First Name Last Name Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Signature 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. Dependent First Name Signature Authorized Agent for Insurer or TPA (if self-insured) First Name Witness, Last Name Honorable Court in County, , one of the Justices of the Last Name day of , 20 Signature (Attorney must sign above and type name below) In case of a change in the status of any dependent, this agreement shall be modified by Supplemental Agreement or order of a Workers' Compensation Judge in accordance with Attorney(s) for the Pennsylvania Workers' Compensation Act. Weekly wages must be computed in accordance with Section 309 of the Act. Office and P.O. Address NOTICE: Agreement should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left corner on the front. A copy must be sent to the dependent. Telephone No.: Any individual filing misleading or incomplete information knowingly and Facsimile No.: 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 E-Mail Address: Pennsylvania Act 165 of 1994. Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com
|
|||||||
