Fillable INFORMAL CONFERENCE AGREEMENT FORM - - EMPLOYEE EMPLOYER (Pennsylvania)

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INFORMAL CONFERENCE AGREEMENT FORM - - EMPLOYEE EMPLOYER (Pennsylvania)

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DEPARTMENT OF LABOR & INDUSTRY
WORKERS’ COMPENSATION OFFICE OF ADJUDICATION
INFORMAL CONFERENCE
AGREEMENT FORM
EMPLOYEE EMPLOYER
INSURER or THIRD PARTY ADMINISTRATOR
(if self-insured)
1. This matter is currently pending on
before Workers’ Compensation Judge
2. On
- -
  
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
DATE OF INJURY WCAIS CLAIM NUMBER
- -
MM DD YYYY
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
TYPE OF PETITION(S)
NAME
ADDRESS
the parties led a Notice of Request for an Informal Conference pursuant to Section
MM DD YYYY
402.1 of the Pennsylvania Workers’ Compensation Act.
3. An informal conference was conducted before on
- -
Workers’ Compensation Judge
MM DD YYYY
At that conference, the employee was was not represented by counsel, and the employer was was not
represented by counsel.
4. The parties have agreed upon the following matters at the informal conference:
LIBC-754 REV 04-18 (Page 1)
If necessary, attach separate pages, each signed by all parties, to state fully the matters agreed upon at the conference. If a
Notice of Compensation Payable, Agreement for Compensation, or Supplemental Agreement has/have been executed, attach
such document(s). Complete all required EDI transactions in accordance with the provisions of the EDI Implementation Guide.
Employee’s signature Insurer/Employer’s Agent’s signature
       
Employee’s name (typed/printed)
Employee’s Attorney’s signature
Employee’s Attorney’s name (typed/printed)
Date of this agreement
- -
MM DD YYYY
Insurer/Employer’s Agent’s name (typed/printed)
Insurer/Employer’s Attorney’s signature
Insurer/Employer’s Attorney’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).
Employer Information
Services
717.772.3702
Claims Information Services
toll-free inside PA: 800.482.2383
local & outside PA: 717.772.4447
Hearing Impaired
PA Relay 7-1-1
Email
ra-li-bwc-helpline@pa.gov
*754*
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-754 REV 04-18 (Page 2)
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INFORMAL CONFERENCE AGREEMENT FORM - - EMPLOYEE EMPLOYER (Pennsylvania)

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Completed 9 December 2021

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