Notice Of Reinstatement Of Workers Compensation Benefits {LIBC-763} | Pdf Fpdf Docx | Pennsylvania

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Notice Of Reinstatement Of Workers Compensation Benefits {LIBC-763} | Pdf Fpdf Docx | Pennsylvania

Notice Of Reinstatement Of Workers Compensation Benefits {LIBC-763}

This is a Pennsylvania form that can be used for Workers Comp.

Alternate TextLast updated: 6/14/2018

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DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION NOTICE OF REINSTATEMENT OF002 WORKERS222 COMPENSATION002 BENEFITS002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone DATE OF THIS NOTICE: - - MM DD YYYY DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN 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 # ATTORNEY FOR EMPLOYEE (if known) ATTORNEY FOR INSURER/EMPLOYER (if known) Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number Name Signature Address Address City/Town State ZIP Telephone FEIN A COPY OF THIS FORM AND ATTACHMENTS ARE TO BE PROVIDED TO THE EMPLOYEE AND THE EMPLOYEE222S ATTORNEY (IF KNOWN). (OVER) American LegalNet, Inc. www.FormsWorkFlow.com - - MM DD YYYY your indicated NO - OR- - - MM DD YYYY Employer Information Claims Information Services Email Services Hearing Impaired *763*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com

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