- -
9. Did this problem cause you to stop working? Yes No If yes, give date .
MM DD YYYY
10. Are you back to work with the same employer? Yes No If yes, Regular job Other job/give title
11. Are you back to work with another employer?
Yes No If yes, give name and address of new employer:
.
12. What were your wages at the time of injury? $ Hour Day Week
13. If you have returned to work since your injury or illness, are you earning
More Same Less
.
than you were at the time of injury? Current earnings $ Hour Day Week
14. I am seeking payment for (check all that apply):
- -
- -
Partial disability from thru (date disability ends) or ongoing.
MM DD YYYY
MM DD YYYY
- - - -
Full disability from thru (date disability ends) or ongoing.
MM DD YYYY MM DD YYYY
Medical bills
Counsel fees to be paid by the employer.
Loss or loss of use of arm, hand, nger, leg, foot or toe.
Disgurement (scars) of head, face or neck.
Loss of sight.
Loss of hearing.
Other
15. Is there other pending litigation in this case?
Yes No If yes, explain below:
PLEASE ENTER MY APPEARANCE FOR PETITIONER:
Attorney’s name
Date of petition
PA Attorney ID number
MM DD YYYY
Firm name
- -
Address
Address
City/Town State ZIP
Telephone
Attorney’s signature
Notice: This petition must be lled out as fully as possible. If not ling electronically, the original must be sent to the Workers’ Compensation Oce of Adjudication,
1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. You must send a copy to all other parties, and on the attorneys of all other parties, if the attorneys are
known. 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. Questions regarding the completion of this form may be directed to the Bureau of Workers’ Compensation Claims Information Services.
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).
Employer Information Claims Information Services Hearing Impaired Email
Services toll-free inside PA: 800.482.2383 PA Relay 7-1-1 ra-li-bwc-helpline@pa.gov
717.772.3702 local & outside PA: 717.772.4447
*362*
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-362 REV 08-20 (Page 2)
