DEPARTMENT OF LABOR & INDUSTRY
OFFICE OF ADJUDICATION
PENNSYLVANIA WC HEARING -
INTERESTED PARTY UPDATE REQUEST
Directions: This form is to be used by counsel when there is a discrepancy between the Interested Parties table
in WCAIS and the parties that counsel has for a given matter. Complete this form only for the parties that
are incorrect. Enter the correct information exactly as it should appear. For a WCOA matter, upload
the form as a Miscellaneous Request on the Requests tab of the Dispute Summary. For a WCAB matter, upload
the form as Document Sub-Category “Appeal” or “Petition” as appropriate and then select “Interested Party
Update Request” Document Type drop down on the Documents and Correspondence tab of the Appeal or
Petition Matter. This form is not to be used for making updates to attorney prole information in WCAIS.
* = required eld
Date* WCAIS Claim/DSP/A #*
Attorney*
Name*:
First
Representing*:
PA Bar ID*:
MI Last
Claimant, insurer or employer
ALL FIELDS ABOVE THIS LINE ARE REQUIRED
Claimant
Name:
First MI Last
Address:
Street Address City State ZIP+4
SSN*: (required for update)
Employer
Name:
Address:
Street Address City
Self-Insured
State ZIP+4
FEIN*: (required for update)
Insurer
Name:
Address:
Street Address City State ZIP+4
FEIN*: (required for update)
TPA
Name:
Address:
Street Address City State ZIP+4
FEIN*: (required for update)
Healthcare Provider and Healthcare Professional updates may be made on the second page of this form
LIBC-113 REV 08-19 (Page 1)
