Pennsylvania > Workers Comp
Notice Of AbilityTo Return To Work LIBC-757 - Pennsylvania
| Notice Of AbilityTo Return To Work Form. This is a Pennsylvania form and can be used in Workers Comp . |
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COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS COMPENSATION Social Security Number: - - NOTICE OF ABILITY 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 TO RETURN TO WORK Date of Injury / / MM DD YYYY (TOLL FREE) 800-482-2383 TTY 800-362-4228 PA BWC Claim Number: (IF KNOWN)Employee Employer First Name Last Name Name _______________________________ ____________________________________________________________________________________________________________________ Street 1 Street 1 ______________________________________________________________________________________________________________________________________________________ Street 2 Street 2 ______________________________________________________________________________________________________________________________________________________ City/Town State Zip Code City/Town State Zip Code __________________________________________ __________ __________-_________________________________________________ __________ _________-_______ County TelephoneCounty ___________________________________________ (______) _______-__________________________________________________ Telephone FEIN (______) _______-____________________ _____________________________ Insurer or Third Party Administrator (if self-insured)DATE OF THIS NOTICE: ______/______/______ Name MM DD YYYY___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ __________ __________-_______ Telephone Bureau Code (______) _______-___________________________________________________ County ____________________________________ Claim Number FEIN ____________________________________ ______________________________Section 306(b)(3) of the Pennsylvania Workers Compensation Act requires insurers to notify the employee when they receive medical evidence indicating the ability to return to work in some capacity. Receipt of medical evidence indicates your present physical condition or change of condition is: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Attached are all documents supporting these allegations. YOU SHOULD ALSO KNOW You have an obligation to look for available employment. Proof of available employment may jeopardize your right to receive ongoing benefits. You have the right to consult with an attorney in order to obtain evidence to challenge the insurers contentions. 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 and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-757 REV 5-04 American LegalNet, Inc. www.USCourtForms.com
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