Pennsylvania > Workers Comp
Appeal From Judges Finding Of Fact LIBC-25-26 - Pennsylvania
| Appeal From Judges Finding Of Fact Form. This is a Pennsylvania form and can be used in Workers Comp . |
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LICB-25/26 REV 1-03 COMMONWEALTH OF PENNSYLVANIA APPEAL FROM JUDGES WORKERS COMPENSATION APPEAL BOARD FINDINGS OF FACT CAPITOL ASSOCIATES BUILDING 901 N. 7TH STREET (FRONT), 3RD FLOOR SOUTH AND HARRISBURG, PA 17102-1412 (717)783-7838 CONCLUSIONS OF LAW _______________________________________________________________________ CLAIMANT Date: _____________________________________________ Petition Type: _____________________________________________________________________________________________________________ ADDRESS Circulation Date: __________________________________________________________________________________________________________ Social Security Number: ___________________________ CITY STATE ZIP CODE Bureau Claim Number: ______________________________ VS. Date of Injury: ____________________________________________________________________________________________________________ _______________________________________________________________________ DEFENDANT INSURANCE CARRIER _______________________________________________________________________ _______________________________________________________________________ ADDRESS ADDRESS _______________________________________________________________________ _______________________________________________________________________ CITY STATE ZIP CODE CITY ST A TE ZIP C ODETO THE WORKERS COMPENSATION APPEAL BOARD, HARRISBURG , PENNSYLVANIA: I hereby appeal from the decision of Judge ___________________________________ and allege the following findings offact are in error and are not supported by substantial evidence, or contain other errors as specifically set forth below. A copyof the Judges decision is attached. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I hereby appeal from the decision of Judge ________________________________ and specify the following errors of law committed by the said Judge, and the reasons why the decision does not conform to the provisions of the Workers Compensation Act or the Occupational Disease Act. A copy of the Judges decision is attached. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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