Fillable LIBC-377 Int LIBC-377 Int (Pennsylvania)

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LIBC-377 Int LIBC-377 Int (Pennsylvania)

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DEPARTMENT OF LABOR & INDUSTRY
WORKERS’ COMPENSATION OFFICE OF ADJUDICATION
ANSWER TO PETITION TO/FOR:
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
INJURY INFORMATION
Provide the following information if Employer has accepted
liability for this injury:
Part of body injured
Nature of injury
Accident/injury description narr
ativ
e
Check if occupational disease
DATE OF INJURY WCAIS CLAIM NUMBER
- -
MM DD YYYY
EMPLOYER
Name
Address
Address
Cit
y/T
own State ZIP
Count
y
Telephone FEIN
VS. INSURER 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 #
TO YOUR HONORABLE JUDGE:
In answer to the following petition(s):
Review medical treatment and/or billing Terminate compensation benets
Modify compensation benets Suspend compensation benets
Review compensation benets Reinstate compensation benets
Set aside nal receipt Penalties
Joinder of additional defendant
In the above case, the respondent respectfully pleads as follows:
(Answer in numerical order in response to corresponding numbers on petitions.)
LIBC-377 REV 04-18 (Page 1)
Compensation presently payable under: Notice of compensation payable Agreement
Supplemental agreement Award
Additional information:
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 ofce 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
MM DD YYYY
Firm name
Address
Address
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).
Employer Information
Services
717.772.3702
Claims Informatio
n 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
Date led
- -
*377*
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-377 REV 04-18 (Page 2)
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LIBC-377 Int LIBC-377 Int (Pennsylvania)

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Completed 14 October 2021

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