Employers Insurance Information Sheet {LIBC-500} | Pdf Fpdf Docx | Pennsylvania

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Employers Insurance Information Sheet {LIBC-500} | Pdf Fpdf Docx | Pennsylvania

Employers Insurance Information Sheet {LIBC-500}

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

Alternate TextLast updated: 5/17/2018

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DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION REMEMBER: IT IS IMPORTANT TO TELL YOUR EMPLOYER 002ABOUT YOUR INJURY002 Employer Name: IF INSURED: Date Posted: IF SOMEONE OTHER THAN INSURER IS HANDLING CLAIMS: IF SELF-INSURED IF SOMEONE OTHER THAN SELF-INSURER IS HANDLING CLAIMS: Employer Information Claims Information Services Email Services Hearing Impaired *500*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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