Pennsylvania > Workers Comp
Claim Petition For Benefits From Uninsured Employer Guaranty Fund And Uninsured Employer LIBC-550 - Pennsylvania
| Claim Petition For Benefits From Uninsured Employer Guaranty Fund And Uninsured Employer Form. This is a Pennsylvania form and can be used in Workers Comp . |
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COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 TTY 800-362-4228 EMPLOYEE SOCIAL SECURITY NUMBER CLAIM PETITION FOR BENEFITS FROM THE UNINSURED EMPLOYER AND THE UNINSURED EMPLOYERS GUARANTY FUND DATE OF INJURY MONTH DAY YEAR PA BWC CLAIM NUMBER (IF KNOWN) EMPLOYEE First Name Last Name If Deceased - Dependent or Guardian First Name Last Name Address Address City/Town County Telephone ( ) State Zip EMPLOYER Name Address Address City/Town VS. County Telephone ( AND ) State Zip Pennsylvania Uninsured Employers Guaranty Fund P.O. Box 1774 Harrisburg, PA 17105-1774 Employees should file this Petition if they are seeking an award against their employer and the Uninsured Employers Guaranty Fund because their employer did not maintain workers' compensation insurance coverage and was not approved as a self-insurer at the time of the alleged injury. NOTE: You may not file this petition until 21 days after you filed a Notice of Claim Against Uninsured Employer, Form LIBC-551. 1. Have you filed a Notice of Claim Against Uninsured Employer, Form LIBC-551? Yes No 2. Complete description of injury or illness including all parts of body affected. If fatality, provide cause of death. MONTH DAY YEAR 3. If occupational disease, give the last date of employment MONTH DAY YEAR and/or last date of exposure MONTH DAY YEAR 4. Give date of injury or onset of disease 5. How did the injury or disease occur? 6. Did injury or disease occur on employer's premises? Yes No Where? (Be specific.) MONTH DAY YEAR 7. Notice of your injury or disease was served on your employer on following manner: 8. What was your job title at the time of injury or disease? in the LIBC-550 REV 06-11 (Page 1) 550 0611 9. Were you working for more than one employer at the time of your injury? Yes No If Yes, list additional employers: MONTH DAY YEAR 10. Did this problem cause you to stop working? 11. Are you back to work with the same employer? 12. Are you working with another employer? Yes Yes Yes No If Yes, give date. No If Yes, Regular Job Other Job / Give Title. No If Yes, give name and address of new employer: 13. What were your weekly wages at the time of injury? $ 14. If you have returned to work since your injury or illness, are you earning than you were at the time of injury? Current weekly wages $ 15. I am seeking payment for (check all that apply): Loss of Wages Partial disability from Full disability from MONTH DAY YEAR MONTH DAY YEAR More Same Less to MONTH DAY YEAR MONTH DAY YEAR to Medical bills (give name of doctor/hospital, address, type of treatment and bill in space below). Counsel fees to be paid by the employer. (Note: The Fund is not subject to unreasonable contest attorney fees.) Loss or loss of use of arm, hand, finger, leg, foot or toe. Disfigurement (scars) of head, face or neck. Injury or disease resulting in death. Date of death. Loss of sight. Loss of hearing. 16. Have you filed any other Workers' Compensation Petition(s) related to this injury/fatality? If Yes, PA BWC Claim Number (if known) PLEASE ENTER MY APPEARANCE FOR PETITIONER: DATE OF PETITION MONTH DAY YEAR Yes No Attorney Name PA Attorney ID# Name of Firm Address Address City/Town Telephone ( ) State Zip MONTH DAY YEAR A copy of this petition has been sent to the employer and the Fund. Employee or Dependent Signature Attorney NOTICE: This Petition must be filled out as fully as possible. The original must be sent to the Bureau of Workers' Compensation, 1171 South Cameron Street, Room 103, Harrisburg, PA 17104-2501. You must send a copy of this Petition to the employer and Guaranty Fund, P.O. Box 1774, Harrisburg, PA 17105-1774. Information on the completion of this form may be obtained by calling the Bureau of Workers' Compensation 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 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). Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-550 REV 06-11 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com
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