Pennsylvania > Workers Comp
Petition To LIBC-378 - Pennsylvania
| Petition To Form. This is a Pennsylvania form and can be used in Workers Comp . |
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EMPLOYEE SOCIAL SECURITY NUMBER COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY OFFICE OF ADJUDICATION - PETITIONS SECTION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 TTY 800-362-4228 (Check any that apply) DATE OF INJURY PETITION TO/FOR: MONTH DAY PA BWC CLAIM NUMBER (IF KNOWN) YEAR Penalties (For violation of the Act, Rules and Regulations) Review Medical Treatment and/or Billing Terminate Compensation Benefits (Stop payment of Workers' Compensation) Terminate Compensation: Based upon physician's affidavit, a special supersedeas hearing to be scheduled Modify Compensation Benefits (Reduce/increase amount of Workers' Compensation) Suspend Compensation Benefits Review Compensation Benefits (Ask Judge to Review Agreement/Notice for mistakes) Review Compensation Benefit Offset Reinstate Compensation Benefits Set aside Final Receipt (Ask Judge to set aside Agreement to Stop Compensation) Seek approval of a Compromise and Release Agreement (Ask Judge to approve settlement) This petition is filed on behalf of: Employee Employer/Insurer EMPLOYEE First Name Last Name If Deceased - Dependent or Guardian First Name Last Name Address Address City/Town County Telephone ( ) State Zip EMPLOYER Name Address Address City/Town County Telephone ( ) FEIN State Zip VS. INSURER or THIRD PARTY ADMINISTRATOR (if self insured) Name Address Address City/Town Telephone County Claim # FEIN ( ) State Zip Bureau Code NOTICE: This petition must be filed with the Workers' Compensation Office of Adjudication - Petitions Section, with a copy being served on the opposing party. If this petition is filed by the insurer or employer, they must attach a Notice to Employee, Form LIBC-758, to the employee's copy. Questions regarding the completion of this form may be directed to the Workers' Compensation Helpline at 800-482-2383. TO YOUR HONORABLE JUDGE: MONTH DAY YEAR As of the above petitioner requests the Workers' Compensation Judge to order the above action for the following reason(s): Full Recovery Special Job Offered Work Generally Available Able to Return to Unrestricted Work Has Returned to Work Reasonable Treatment Refused Resolution to Specific Loss Incorrect Description of Injury Incorrect Average Weekly Wage 10. 11. 12. 13. 14. 15. 16. 17. Medical Bills Unpaid Medical Bills Not Related Worsening of Condition Injury Causing Decreased Earning Power Section 314 Order Violated Voluntary Withdrawal from Workforce Violation of the Act, Rules and Regulations Subrogation, Credit for U.C. Social Security Third Party Recovery S&A Pension 1. 2. 3. 4. 5. 6. 7. 8. 9. 18. Other 378 1011 BACK OF FORM MUST BE COMPLETED LIBC-378 REV 10-11 (Page 1) Compensation benefits are being paid have been paid based on a: MONTH DAY YEAR Notice of Compensation Payable dated MONTH DAY YEAR Agreement dated MONTH DAY YEAR Supplemental Agreement dated MONTH DAY YEAR Judge's Award dated MONTH DAY YEAR Board Order dated MONTH DAY YEAR Court Order dated A supersedeas is requested pursuant to Section 413(A.2). If Yes, list reasons: Compensation has been or is being paid as follows: Weekly rate $ Average weekly wage $ MONTH DAY Yes No . . Paid for Weeks Days to Date YEAR Date of most recent payment MONTH DAY YEAR I hereby certify that a copy of this petition has been served on the opposing party on at the address shown on the face of this form. PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney Name Firm Name Address Address City/Town Telephone ( ) Counsel for Respondent (if known): Name Firm Name Address Address State Zip Code PA Attorney ID Number - City/Town Telephone ( ) State Zip Code PA Attorney ID Number - - - Signature of Petitioner or Representative Name of Petitioner or Representative 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, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa.C.S.A. §4117 (relating to insurance fraud). DATE OF PETITION MONTH DAY YEAR Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-378 REV 10-11 (Page 2)
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