Fillable NOTICE OF REQUEST FOR AN INFORMAL CONFERENCE (Pennsylvania)

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NOTICE OF REQUEST FOR AN INFORMAL CONFERENCE (Pennsylvania)

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DEPARTMENT OF LABOR & INDUSTRY
WORKERS’ COMPENSATION OFFICE OF ADJUDICATION
NOTICE OF REQUEST FOR AN
INFORMAL CONFERENCE
EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
County
Telephone
WCOA USE ONLY
Date ling received Date of conference
- - - -
MM DD YYYY MM DD YYYY
Informal conference judge
(Print)
Was a time extension granted? Yes No
Was a resolution reached? Yes No Partial
DATE OF INJURY WCAIS CLAIM NUMBER
- -
MM DD YYYY
EMPLOYER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
INSURER or THIRD PARTY ADMINISTRATOR
(if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
Pursuant to section 402.1 of the Act, the parties herewith request that the Department schedule an informal conference in
the above case.
The employee will be represented by an attorney at the informal conference:
Yes No
Employee counsel
Employer counsel
Adjudicating judge
Suggested informal
conference judge
(if agreed upon)
Last name
Last name
Last name
Last name
First name
First name
First name
First name PA Attorney ID number
PA Attorney ID number
Pending petition(s):
Notice: This notice must be lled out as fully as possible. The original must be sent to the workers’ compensation judge (adjudicating judge) who has the assigned
petition. If there is no pending petition and one is attached, then le it with the Workers’ Compensation Of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 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 Bureau of Workers’ Compensation Claims Information Services.
Date of this notice
Attorney’s signature
Attorney’s name
(typed/printed)
ZIP
Employee/Dependent/Guardian/Personal Representative signature
Telephone
COUNSEL FOR PARTY SUBMITTING REQUEST:
Attorney’s name
PA Attorney ID number
Firm name
Address
Address
City/Town State
Telephone
LIBC-753 REV 04-18 (Page 1)
- -
MM DD YYYY
INSTRUCTIONS AND PROCEDURES
• In order to request an informal conference, you must obtain the agreement of all parties in your matter to participate in
the informal conference.
• To le this form, mail original to the workers’ compensation judge (adjudicating judge) who has the assigned petition.
If there is no pending petition and one is attached, then le it with the Workers’ Compensation Ofce of Adjudication,
1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. This form may be led with the signature of a
representative of only one party, but only with the knowledge and consent of all parties.
• The adjudicating judge is the workers’ compensation judge who has been assigned to hold hearings and issue decisions
relating to a petition(s).
• The parties may suggest an informal conference judge or hearing ofcer, but the assignment will be made by the judge
manager from the district where the claim is pending.
• The informal conference judge or hearing ofcer will assign a date, location and time for the informal conference to be
held within 35 days of ling of the request and may request information from the parties seeking an informal conference.
• There shall be no time extension without written agreement of all the parties which shall be led with the informal
conference judge or hearing ofcer.
• The adjudicating judge shall not be assigned to an informal conference.
• “All communications, verbal or written, from the parties to the workers’ compensation judge or hearing ofcer and any
information and evidence presented to the workers’ compensation judge or hearing ofcer during the informal conference
proceedings are condential and shall not be a part of the record of testimony.” WC Act, 402.1(b)(ii).
• “Each party may be represented, but the employer may only be represented by an attorney at the informal conference if
the employee is also represented by an attorney at the informal conference.” WC Act, 402.1 (b)(iii).
• All participants at the informal conference must have authority to resolve the matter in controversy.
• The informal conference judge or hearing ofcer conducting the informal conference may meet separately with each of
the parties during the conference and may use other reasonable means to encourage an informal resolution.
• If the parties resolve the petition(s), the party who led the pending petition(s) must notify the adjudicating judge that
the petition(s) is (are) resolved.
• The informal conference judge or hearing ofcer conducting the informal conference shall reduce the agreement reached
to writing which will be signed by the parties. The original informal conference agreement and attached documents shall
be led with the adjudicating judge with the copy to the informal conference judge or hearing ofcer.
• If the informal conference does not resolve the case, it will be returned to the assigned adjudicating judge. The parties
may jointly request the adjudicating judge to reassign the case to the workers’ compensation judge who conducted the
informal conference if the conference was held by a workers’ compensation judge subject to WCOA approval.
• Parties may agree to pursue the Compromise and Release procedures as a result of the informal conference through the
adjudicating judge, but the Compromise and Release Agreements will not be accepted at informal conferences.
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 Email
Services toll-free inside PA: 800.482.2383 ra-li-bwc-helpline@pa.gov
717.772.3702 local & outside PA: 717.772.4447
Hearing Impaired
PA Relay 7-1-1
*753*
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-753 REV 04-18 (Page 2)
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NOTICE OF REQUEST FOR AN INFORMAL CONFERENCE (Pennsylvania)

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Completed 9 December 2021

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