(I)(we) further submit for your consideration the following additional facts:
For the above reasons, (I)(we) request that your Honorable Judge the said petition for
commutation in the captioned case.
WHEREFORE, the respondent requests that the petition be dismissed or in the alternative disallowed.
Notice: This answer must be lled out as fully as possible. If not ling electronically, the original must be sent to the ofce of the Judge to whom the case is assigned.
You must send a copy to all unrepresented parties, and to the attorney of record for all other parties which are represented by counsel. A Proof of Service must be
attached. A Proof of Service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if known. Answers
must be led within 20 days of the assignment of the petition. Questions regarding the completion of this form may be directed to the Bureau of Workers’ Compensation
Claims Information Services.
PLEASE ENTER MY APPEARANCE FOR RESPONDENT:
Attorney’s name
PA Attorney ID number
Firm name
Date led
Address
Address
MM DD YYYY
City/Town State ZIP
Telephone
Attorney’s signature Attorney’s name
(typed/printed)
Respondent’s signature Respondent’s name
(typed/printed)
Any individual ling misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
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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
He
aring Impaired
PA Relay 7-1-1
*35*
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-35 04-18 (Page 2)
