Claim Petition For Additional Compensation From Subsecquent Injury Fund {LIBC-375}

DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION CLAIM PETITION FOR ADDITIONAL002 COMPENSATION FROM THE SUBSEQUENT002 INJURY FUND PURSUANT TO SECTION 306.1002 OF THE WORKERS222 COMPENSATION ACT002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - DATE OF INJURYMM DD YYYY EMPLOYEE First name Last name Date of birth If deceased - Dependent/Guardian/Personal Representative First name Last name Address Address City/Town State ZIP County Telephone INJURY INFORMATION Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease WCAIS CLAIM NUMBER - - EMPLOYERName Address Address City/Town State ZIP County Telephone FEIN VS. INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim # AND 002Commonwealth of Pennsylvania Department of Labor & Industry002 1171 South Cameron St Harrisburg, PA 17104-2501 -- MM DD YYYY a.Was this loss or loss of use work-related? Yes No If Yes, name and address of employer: -- MM DD YYYY American LegalNet, Inc. www.FormsWorkFlow.com 4.Complete description of second (subsequent) loss or loss of use injury.a.Was this loss of use injury work-related? Yes No If yes, name and address of employer: 5.Is there pending workers222 compensation litigation or a previous Workers222 Compensation Judge222s decision regarding the second(subsequent) loss or loss or use injury? Yes No -- MM DD YYYY b.If a Workers222 Compensation Judge222s decision was rendered, what was the circulation date of the decision? -- MM DD YYYY -- MM DD YYYY 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 the injury? Current earnings $ Hour Day or Week . agency? Yes No If yes, please list. PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney222s name PA Attorney ID number Firm name Date of petitionMM DD YYYY Address -- Address City/Town State ZIP Telephone Attorney222s signature N77 P.S. 2471039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. 2474117 (relating to insurance fraud). Employer Information Claims Information Services Email Services toll-free inside PA: 800.482.2383 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 Hearing Impaired *375*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com