Occupational Disease Claim Petition {LIBC-396}

OCCUPATIONAL DISEASE CLAIM PETITION MONTHLY COMPENSATION FOR First name Last name Date of birth Address Address City/Town State ZIP County Telephone VS Commonwealth of Pennsylvania Department of Labor & Industry 1171 South Cameron Street Harrisburg, PA 17104-2501 Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION . -- 1.003 My last date of employment or self-employment in any occupation was002 MM DD YYYYI became totally disabled on002 MM DD YYYY002 Coal Workers222 Pneumoconiosis Silicosis Anthraco-Silicosis Asbestosis 3.003 My total disability is a result of employment in a hazardous occupation having a:002 Coal hazard002 Asbestos hazard Silica hazard 4.003 I was employed in the Commonwealth of Pennsylvania at least two years preceding the above date of the disability, as follows:002(List all employment in the hazardous occupation.)002 NAME OF EMPLOYER IN PENNSYLVANIA003 ADDRESS DATES OF EMPLOYMENT FROM TO MM-DD-YYYY MM-DD-YYYY -- American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 -- MM DD YYYY (b) Claim petition: Pending Dismissed Withdrawn 6.Ihave have not Therefore, I hereby petition the Department of Labor & Industry to award monthly compensation to me at the rate set forth under the provisions of Section 301 (i) of the 1939 Occupational Disease Act, as amended. Petitioner/Employee signature PLEASE ENTER MY APPEARANCE FOR PETITIONER: Date of petition Attorney222s name PA Attorney ID number Firm name Address Address City/Town Telephone State ZIP MM DD YYYY --Attorney222s signature NINSTRUCTIONS TO CLAIMANT Failure to comply with these instructions will necessitate the return of your petition. Employee must sign this document. Attach two recent photographs. Place your signature and last four digits of Social Security Number on the reverse side of each photograph. 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 *396*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com