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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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DEPARTMENT OF LABOR & INDUSTRY WORKERS' COMPENSATION OFFICE OF ADJUDICATION DEFENDANT'S ANSWER TO CLAIM PETITION UNDER PA WORKERS' COMPENSATION ACT DATE OF INJURY WCAIS CLAIM NUMBER EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER EMPLOYEE First name Last name MM DD YYYY EMPLOYER Name Address Address City/Town County Telephone FEIN State ZIP Date of birth If deceased - Dependent/Guardian/Personal Representative First name Last name Address Address City/Town County Telephone State ZIP VS. INSURER, FUND or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town County Telephone NAIC code Insurer/TPA claim # FEIN or Insurer code State ZIP INJURY INFORMATION Provide the following information if Employer has accepted liability for this injury: Part of body injured Nature of injury Accident/injury description narrative "FUND" SHALL MEAN THE UNINSURED EMPLOYERS GUARANTY FUND, SUBSEQUENT INJURY FUND, SELF-INSURANCE GUARANTY FUND OR PRE-SELF-INSURANCE GUARANTY FUND. Check if occupational disease TO YOUR HONORABLE JUDGE: In answer to the captioned claim, the defendant respectfully pleads as follows: (Answer must be identified by numerical order in direct response to corresponding numbered allegations asserted in the claim petition.) LIBC-374 REV 09-13 (Page 1) American LegalNet, Inc. As a matter of further defense, the defendant states the following: PLEASE ENTER MY APPEARANCE FOR DEFENDANT: Attorney's name PA Attorney ID number Firm name Address Address City/Town Telephone Date filed MM DD YYYY State ZIP Attorney's signature Attorney's name (typed/printed) Defendant's signature Defendant's name (typed/printed) Notice: This answer must be filled out as fully as possible. If not filing electronically, the original must be sent to the Workers' Compensation Office of Adjudication, 1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. You must send a copy to all unrepresented parties, and to the attorney of record for all other parties which are represented by counsel. A Proof of Service must be attached. A Proof of Service is a signed statement signed by you verifying that you have sent a copy of the answer to all parties and their attorneys, if known. Answers must be filed within 20 days of the assignment of the petition. Every fact alleged in the petition not specifically denied by this answer shall be deemed to be admitted. Questions regarding the completion of this form may be directed to the Bureau of Workers' Compensation Claims Information Services. Any individual filing misleading or incomplete information knowingly and with the 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). Employer Information Services 717.772.3702 Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447 Hearing Impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991 Email *374* Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-374 REV 09-13 (Page 2) American LegalNet, Inc.
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