Pennsylvania > Workers Comp
Notice Of Compensation Payable LIBC-495 - Pennsylvania
| Notice Of Compensation Payable Form. This is a Pennsylvania form and can be used in Workers Comp . |
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EMPLOYEE SOCIALSECURITYNUMBER COMMONWEALTH OF PENNSYLVANIA DEPARTMENTOF LABOR AND INDUSTRY NOTICE OF COMPENSATION -- BUREAU OF WORKERSCOMPENSATION 1171 S. CAMERON STREET, ROOM 103 PAYABLE HARRISBURG, PA 17104-2501 DATE OF INJURY (TOLLFREE) 800-482-2383 DATE OF NOTICE -- -- MONTH DAY YEAR PA BWC CLAIM NUMBER (IF KNOWN) MONTH DAY YEAR EMPLOYEE EMPLOYER First Name Name Last Name Address Address Address Address City/Town State Zip City/Town State Zip County County () Telephone FEIN () Telephone INSURER or THIRD PARTYADMINISTRATOR (if self insured) INJURY INFORMATION Name Body Part(s) affected Address Type of Injury Address Description of Injury City/Town State Zip () Telephone Bureau Code Claim # FEIN Check if Occupational Disease NOTICE TO EMPLOYER: This Notice should be clearly completed, (preferably typed) and mailed to the Bureau at the address in the upper left corner.A copy must be sent to the injured employee with the first payment of comp ensation. NOTICE TO EMPLOYEE: If any questions arise regarding these payments, contact the representative named at the bottom of this Notice. If you cannotresolve a problem with the employer representative, you may call the Bur eau at 800-482-2383. Compensation is payable as follows: Check only if compensation for medical treatment (medical only, no loss of wages) will be paid subject to the WorkersCompensation Act. Compensation for medical treatment is payable from date of injury. For compensation for medical treatment only, you should not complete numbers 1 through 5. 1. Weekly compensation rate $ . Based on an average weekly wage of $ . MONTH DAY YEAR (Compensation for loss of wages is payable for first 7 days only if dis ability extends - - 14 or more days; compensation for medical treatment is payable from the date of2. Payments begin on injury.) MONTH DAY YEAR - - 3. Date first check mailed If the date exceeds the 21-Rule, check this box and explain on back of this form.4. Payments will hereafter be made:Weekly Biweekly Other (Specify): Any termination, suspension or modification of these payments must be ma de by agreement, final receipt, administrative or judicial determination, or as otherwise provided in the WorkersCompensation Act or Regulations of the Department. 5. If injury involves loss under Section 306(c) (except for disfiguremen t of the head, face or neck) and employee has returned to work, complete the following information. (a) Compensation is payable for weeks days for loss or loss of use of . MONTH DAY YEAR (b) Employee returned to work without loss of income on - - (c) Healing period payable for weeks days (Up to (b) above and subject to 7-day waiting period) (d) Total (a) and (c) payable weeks days. (e) Credit taken for disability benefits paid $ . 495 0903 Name of Claims Representative Phone Number ( ) Signature of Claims Representative LIBC-495 REV 9-03 (OVER) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 LIBC-495 6. Remarks Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania WorkersCompensation Act and may also be subject to criminal and civil penalties through Penn sylvania Act 165. American LegalNet, Inc. www.USCourtForms.com
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