Fillable (Check any that apply) (Pennsylvania)

Fill Online, Printable, Fillable, Blank (Check any that apply) (Pennsylvania) Form

Use Fill to complete blank online PENNSYLVANIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

(Check any that apply) (Pennsylvania)

On average this form takes 31 minutes to complete

The (Check any that apply) (Pennsylvania) form is 2 pages long and contains:

  • 0 signatures
  • 44 check-boxes
  • 103 other fields

Country of origin: US
File type: PDF

BROWSE PENNSYLVANIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
PETITION TO/FOR:
(Check any that apply)
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
Modify compensation benets
(Reduce/increase amount of workers’ compensation)
Penalties (For violation of the act, rules and regulations)
Reinstate compensation benets
Review compensation benets
(Ask Judge to Review Agreement/Notice for mistakes)
Review compensation benets oset
Review medical treatment and/or billing
DATE OF INJURY WCAIS CLAIM NUMBER
- -
MM DD YYYY
Seek approval of a compromise and release agreement
(Ask judge to approve settlement)
Set aside nal receipt
(Ask judge to set aside agreement to stop compensation)
Suspend compensation benets
Terminate compensation: Based upon physician’s adavit,
a special supersedeas hearing to be scheduled
Terminate compensation benets
(Employee fully recovered without any disability)
This petition is led on behalf of: Employee Employer/Insurer Healthcare Provider/Professional
EMPLOYEE
First name
Last name
Date of birth
If deceased - Dependent/Guardian/Personal Representative
First name
Last name
Address
Address
City/Town State ZIP
County
INJURY INFORMATION
Telephone
Provide the following information if Employer has accepted
liability for this injury:
Part of body injured
Nature of injury
Accident/injury description narrative
Check if occupational disease
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
VS. INSURER, FUND 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 #
“FUND” SHALL MEAN THE UNINSURED EMPLOYERS
GUARANTY FUND, SUBSEQUENT INJURY FUND,
SELF-INSURANCE GUARANTY FUND OR
PRE-SELF-INSURANCE GUARANTY FUND.
TO YOUR HONORABLE JUDGE:
The above petitioner requests the workers’ compensation judge to order the above action as of
for the following reason(s).
MM DD YYYY
1. Full recovery 10. Medical bills unpaid
2. Specic job oered 11. Medical bills not related
3. Work generally available 12. Worsening of condition
4. Able to return to unrestricted work 13. Injury causing decreased earning power
5. Has returned to work 14. Section 314 order violated
6. Reasonable treatment refused 15. Voluntary withdrawal from workforce
7. Resolution to specic loss 16. Violation of the act, rules and regulations
8. Incorrect description of injury 17. Subrogation, credit or oset for
9. Incorrect average weekly wage UC Social Security Third party recovery
S&A Pension
- -
LIBC-378 REV 08-20 (Page 1)
DEPARTMENT OF LABOR & INDUSTRY
WORKERS’ COMPENSATION 2)),&(OF ADJUDICATION
18. Other
Have not been paid
Being paid
Have been paid based on a:
Notice of compensation
payable dated
Agreement dated
Supplemental agreement
dated
Compensation benets
MM
MM
MM
-
-
-
DD
DD
DD
-
-
-
YYYY
YYYY
YYYY
Judge’s order dated
Board order dated
Court order dated
MM
MM
MM
-
-
-
DD
DD
DD
-
-
-
YYYY
YYYY
YYYY
This is an Act 46 (reghter cancer) claim
Is supersedeas being requested pursuant to Section 413(A.2)?
If yes, list reasons:
Yes No
Average weekly wage $
Applicable weekly total disability rate $
Date of most recent payment
- -
Amount $
.
.
.
MM DD YYYY
PLEASE ENTER MY APPEARANCE FOR PETITIONER:
Attorney’s name
PA attorney ID number
Firm name
Address
Address
City/Town State ZIP
Telephone
Petitioner or Representative’s signature
Petitioner or Representative’s name
(typed/printed)
COUNSEL FOR RESPONDENT (if known):
Attorney’s name
PA attorney ID number
Firm name
Address
Address
City/Town State ZIP
Telephone
Date of petition
- -
MM DD YYYY
Notice: This petition must be lled out as fully as possible. If not ling electronically, the original must be sent to the Workers’ Compensation Oce of Adjudication,
1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. You must send a copy to all other parties, and to 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 at-
torneys, if known. Questions regarding the completion of this form may be directed to 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
*378*
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-378 REV 08-20 (Page 2)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

(Check any that apply) (Pennsylvania)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 4 November 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document