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Employees Affidavit And Waiver Of Workers Compensation Benefits And Statement Of Religious Sect LIBC-14B - Pennsylvania
| Employees Affidavit And Waiver Of Workers Compensation Benefits And Statement Of Religious Sect Form. This is a Pennsylvania form and can be used in Workers Comp . |
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LIBC-14B REV 7-02 COMMONWEALTH OF PENNSYLVANIA EMPLOYES AFFIDAVIT AND WAIVER OF DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS COMPENSATION WORKERS COMPENSATION BENEFITS 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 AND STATEMENT OF RELIGIOUS SECT (To be filed with the 304.2 Application for Religious Exception) EMPLOYE EMPLOYER STREET ADDRESS STREET ADDRESS CITY/TOWN STATE ZIP CODE CITY/TOWN STATE ZIP CODE EMPLOYE SOCIAL SECURITY NUMBER WAIVER OF WORKERS COMPENSATION AND AFFIDAVIT I, _______________________________ , do hereby state and affirm that I am a member of ______________ EMPLOYE ____________________________________ . Its established tenets and/or teachings conscientiously oppose RELIGIOUS SECT OR DIVISION member acceptance of any public or private insurance benefits which make payments in the event of death, disability, old age, retirement, or towards the cost of medical bills and provisio n of services for medical bills (including the benefits of any insurance system established by the Fede ral Social Security Act), and I adhere to saidtenets and/or teachings. I am, therefore, knowingly and voluntarily waiv ing my rights to any benefits under the Pennsylvania Workers Compensation Act. Subscribed and affirmed to before me this _______ day of __________________ , 20 ____ SIGNATURE OF EMPLOYE (OR PARENT OR GUARDIAN IN CASE OF MINOR NOTARY PUBLIC (SEAL) STATEMENT OF RELIGIOUS SECT I, ____________________________________ ,hereby state and affirm that I am the religious leader of __________ RELIGIOUS SECT LEADER ________________________________ , and I verify that _____________________________ is a current RELIGIOUS SECT ABOVE-NAMED EMPLOYE member of this sect. I state and affirm that this religious sect has est ablished tenets and/or teachings which opposeits members acceptance of any public or private insurance benefits w hich make payments in the event of death, disability, old age, retirement, or toward the cost of medical bills and provision of services for medical bills (includ-ing the benefits of any insurance system established by the Federal Soci al Security Act). Furthermore, I state and affirm that it is the practice, and has been for ________ for members of this sect or division to make provision for NUMBER OF YEARS their dependent members which, in its judgment, is reasonable in view of their general level of living. SIGNATURE OF RELIGIOUS SECT LEADER TITLE DATE American LegalNet, Inc. www.USCourtForms.com
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