Claim Petition For Workers Compensation {LIBC-362} | Pdf Fpdf Doc Docx | KnoxLaw

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Claim Petition For Workers Compensation {LIBC-362} | Pdf Fpdf Doc Docx | KnoxLaw

Claim Petition For Workers Compensation {LIBC-362}

This is a KnoxLaw form that can be used for Workers Compensation within Pennsylvania.

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EMPLOYEE SOCIAL SECURITY NUMBER COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 TTY 800-362-4228 CLAIM PETITION FOR WORKERS' COMPENSATION DATE OF INJURY DAY YEAR MONTH 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 County Telephone ( ) FEIN State Zip VS. INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town Telephone ( County Claim # FEIN ) State Zip Bureau Code 1. Complete description of injury or illness including all parts of body affected. (If you are seeking additional compensation from the Subsequent Injury Fund for total disability as a result of a previous permanent loss, or loss of use of one hand, one arm, one foot, one leg or one eye, and a subsequent injury causing loss, or loss of use of, another hand, arm, foot, leg or eye, you must also submit form LIBC-375.) MONTH DAY YEAR 2. If occupational disease, give the last date of employment MONTH DAY YEAR . - and/or last date of exposure - - MONTH DAY YEAR 3. Give date of injury or onset of disease 4. How did the injury or disease happen? - - . 5. Did injury or disease occur on employer's premises? Yes No Where? (Be specific.) MONTH DAY YEAR 6. Notice of your injury or disease was served on your employer on following manner: 7. What was your job title at the time of injury or disease? - - in the LIBC-362 REV 4-02 (OVER) American LegalNet, Inc. www.USCourtForms.com 8. Were you working for more than one employer at the time of your injury? Yes No If Yes, list additional employers: MONTH DAY YEAR 9. Did this problem cause you to stop working? 10. Are you back to work with the same employer? 11. 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: 12. What were your wages at the time of injury? $ . Hour More Day Same Hour or Week Less Day or Week 13. If you have returned to work since your injury or illness, are you earning than you were at the time of injury? Current earnings $ 14. I am seeking payment for (check all that apply): Loss of Wages MONTH DAY YEAR . MONTH DAY YEAR Partial disability from MONTH DAY YEAR to MONTH DAY YEAR Full disability from - - 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. Loss or loss of use of arm, hand, finger, leg, foot or toe. Disfigurement (scars) of head, face, or neck. Loss of sight. Loss of hearing. 15. Other 16. Is there other pending litigation in this case? PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney Name PA Attorney ID Number Firm Name Address Address City/Town Telephone ( ) State Zip Code MONTH Yes No If Yes, explain below: Date of Petition DAY YEAR A copy of this petition has been sent to the employer. Signature Employee 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. A copy must be sent by you to the employer. 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 and may also be subject to criminal and civil penalties through Pennsylvania Act 165. LIBC-362 REV 4-02 American LegalNet, Inc. www.USCourtForms.com

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