Pennsylvania > Workers Comp
Answer To Petition To LIBC-377 - Pennsylvania
| Answer To Petition To Form. This is a Pennsylvania form and can be used in Workers Comp . |
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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 ANSWER TO PETITION TO/FOR: Social Security Number: Date of Injury MM / DD / YYYY (IF KNOWN) PA BWC Claim Number: EMPLOYEE First Name _______________________________ Address Last Name _________________________________________ EMPLOYER Name ___________________________________________________________________________ Address ___________________________________________________________________________ Address ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County _________________________________ Telephone (______) _______-__________________ __________ _________-_______ ___________________________________________________________________________ Address ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County __________ Telephone __________-_______ ___________________________________________ (______) _______-_______________ FEIN ______________________________ VS. INSURER or THIRD PARTY ADMINISTRATOR (if self insured) Name ___________________________________________________________________________ Address ___________________________________________________________________________ Address ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-___________________ County __________________________________ Claim Number __________________________________ __________ Bureau Code __________-_______ ______________________________ FEIN ______________________________ TO YOUR HONORABLE JUDGE: In answer to the following petition(s): Review Medical Treatment and/or Billing Modify Compensation Benefits Review Compensation Benefits Set Aside Final Receipt Joinder of Additional Defendant Terminate Compensation Benefits Suspend Compensation Benefits Reinstate Compensation Benefits Penalties In the above case, the Respondent respectfully pleads as follows: (Answer in numerical order in response to corresponding numbers on petition.) ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ NOTICE: This answer should be clearly completed (preferably typed) and original mailed directly to the office of the Judge to whom the case is assigned. Answers must be filed within 20 days. Every fact alleged in the petition not specifically denied by this answer shall be deemed to be admitted. LIBC-377 REV 10-11 (Page 1) 377 1011 American LegalNet, Inc. www.FormsWorkFlow.com Compensation Presently Payable Under: Notice of Compensation Payable Supplemental Agreement Agreement Award (I) (we) submit the following facts for your consideration: (I) (we) further submit for your consideration the following additional facts: For the above reasons, (I) (we) request that your Honorable Judge ________________________________________ the said petition in the captioned case. Respondent First Name __________________________ Signature Last Name _______________________________________ PLEASE ENTER MY APPEARANCE FOR RESPONDENT: Attorney First Name _____________________________ Firm Name Last Name ___________________________________________ ____________________________________________________________________ ___________________________________________________________________________ Address ___________________________________________________________________________ Address ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-_________________ __________ __________-_______ PA Attorney ID Number ______________________________ Date: _________/____________/_____________ MM DD YYYY Attorney Signature ____________________________________________________________________ Date: _________/____________/_____________ MM DD YYYY 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, 77P.S.§1039.2, and may also be subject to criminal and civil penalties under 18 Pa.C.S.A § 4117 (relating to insurance fraud). Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-377 REV 10-11 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com
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