Pennsylvania > Workers Comp
Defendants Answer To Claim Petition Under Pennsylvania Workers Compensation Act LIBC-374 - Pennsylvania
| Defendants Answer To Claim Petition Under Pennsylvania Workers Compensation Act Form. This is a Pennsylvania form and can be used in Workers Comp . |
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COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 TTY 800-362-4228 DEFENDANT'S ANSWER TO CLAIM PETITION UNDER PENNSYLVANIA WORKERS' COMPENSATION ACT Employer Social Security Number: Date of Injury MM / DD / YYYY (IF KNOWN) PA BWC Claim Number: Employee First Name _______________________________ Street 1 Last Name _________________________________________ Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County _________________________________ Telephone (______) _______-__________________ __________ _________-_______ ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County __________ Telephone __________-_______ ___________________________________________ (______) _______-_______________ FEIN ______________________________ VS. Insurer, Fund or Third Party Administrator (if self-insured) Name ___________________________________________________________________________ Street 1 "FUND" SHALL MEAN THE UNINSURED EMPLOYERS GUARANTY FUND, SUBSEQUENT INJURY FUND, SELF-INSURANCE GUARANTY FUND OR PRE-SELF-INSURANCE GUARANTY FUND. ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-___________________ County __________________________________ Claim Number __________________________________ __________ Bureau Code __________-_______ ______________________________ FEIN ______________________________ TO YOUR HONORABLE JUDGE: In answer to the captioned claim, the Defendant respectfully pleads as follows: (Answers must be identified by numerical order in direct response to corresponding numbered allegations on claim 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 claim petition not specifically denied by this answer shall be deemed to be admitted. LIBC-374 REV 08-11 (Page 1) 374 0811 As a matter of further defense, the Defendant states the following: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ __________________________________________________________________________________________________________ WHEREFORE, the Defendant requests that the claim petition be dismissed or in the alternative disallowed. Defendant First Name __________________________ Signature Last Name _______________________________________ PLEASE ENTER MY APPEARANCE FOR DEFENDANT: Attorney First Name _____________________________ Firm Name Last Name ___________________________________________ ____________________________________________________________________ ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Tel
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