Pennsylvania > Workers Comp
Claim Petition For Additional Compensation From Subsecquent Injury Fund LIBC-375 - Pennsylvania
| Claim Petition For Additional Compensation From Subsecquent Injury Fund Form. This is a Pennsylvania form and can be used in Workers Comp . |
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EMPLOYEE SOCIALSECURITYNUMBER COMMONWEALTH OF PENNSYLVANIA CLAIM PETITION DEPARTMENTOF LABOR AND INDUSTRY -- BUREAU OF WORKERSCOMPENSATION FOR ADDITIONALCOMPENSATION 1171 S. CAMERON STREET, ROOM 103 DATE OF INJURY HARRISBURG, PA 17104-2501 FROM THE SUBSEQUENT INJURY FUND (TOLLFREE) 800-482-2383 PURSUANT TO SECTION 306.1 OF THE TTY800-362-4228 -- WORKERSCOMPENSATION ACT MONTH DAY YEAR PA BWC CLAIM NUMBER (IF KNOWN) EMPLOYEE EMPLOYER First Name Name Address Last Name Address If Deceased - Dependent or Guardian City/Town State Zip First Name County Last Name () Telephone FEIN Address VS. INSURER or THIRD PARTYADMINISTRATOR (if self-insured) Address Name Address City/Town State Zip Address County City/Town State Zip () Telephone Telephone () Bureau Code County Claim # FEIN And Commonwealth of Pennsylvania Department of Labor and Industry Harrisburg, Pennsylvania 17104-2501 An employee seeking additional compensation from the Subsequent Injury Fund should file this petition if the employee has previously incurred (through injury or otherwise) permanent partial disability, through the loss, or loss of use of, one arm, one foot, one leg or one eye, and incurs total disability through a subsequent injury, causing loss, or loss of use of, another hand, arm, foot, leg or eye. 1. Date of first (prior) loss, or loss of use of, one hand, arm, foot, leg or eye, resulting in permanent partial disability. MONTH DAY YEAR -- 2. Complete description of first (prior) loss or loss of use. a. Was this loss or loss of use work-related? Yes No If Yes, name and address of employer: 3. Date of second (subsequent) loss, or loss of use of, another hand, arm, foot, leg or eye, resulting in total disability. MONTH DAY YEAR -- LIBC-375 4-02 (OVER) <<<<<<<<<********>>>>>>>>>>>>> 24.Complete description of second (subsequent) loss or loss of use injury. a. Was this loss or loss of use injury work-related? Yes No If Yes, name and address of employer: 5. Is there pending workerscompensation litigation or a previous Workers Compensation Judges decision regarding the second (subsequent) loss or loss of use injury?Yes No MONTH DAY YEAR a. If Yes, when was the claim petition filed? -- b. If a WorkersCompensation Judges decision was rendered, what was the circulation date of the decision? MONTH DAY YEAR -- c. Was there an award of benefits for a specific loss or loss of use?Yes No i. If Yes, how many weeks of benefits were awarded? ii. On what date did the specific loss award commence? MONTH DAY YEAR -- 6. What were your wages at the time of the second (subsequent) injury?$ Hour Day or Week . 7. If you have returned to work since the second (subsequent) injury, are you earning More Same Less than you were at the time of injury? Current earnings $ Hour Day or Week . a. If Yes, what is your current average weekly wage? $ . 8. Are you entitled to receive any other benefits by reason of your increased disability, either from any state or federal fund or agency? Yes No If Yes, please list. PLEASE ENTER MYAPPEARANCE FOR PETITIONER: Date ofPetition Attorney Name -- PA Attorney ID Number MONTH DAY YEAR A copy of this petition has been sent to the employer.Firm Name Address _____________________________________________________Address Signature City/Town State Zip Code Employee AttorneyTelephone () NOTICE: ThisPetition must be filled out as fully as possible. The original must be sent to the Bureau of WorkersCompensation, 1171 South Cameron Street, Room 103, Harrisburg, PA 17104-2501. A copy must be sent by you to the employer. Information on the completion of this form may be obtained by calling the Bureau of WorkersCompensation Helpline at 800-482-2383. 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 Pennsylvania Act 165. LIBC-3754-02
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