10.26.2016

Filing A Workers’ Compensation Claim In Pennsylvania Is Form-Intensive: Part 2

Today’s blog features a summary in the form of a list of the important documents Filing A Workers' Compensation Claim In Pennsylvania Is Form-Intensive: Part 2 encountered in a Pennsylvania workers’ compensation case. The attorneys at Powell Law have represented injured Pennsylvania workers for 110 years. Here is a list of some forms that may be encountered during the application process:

Title WC Bureau #
Medical Report Form

(A form  completed by a treating physician within ten days of initial treatment and monthly thereafter)

LIBC-9
Appeal from Judge’s Findings

(Appeals a judge’s findings of fact and conclusions of law)

LIBC-25
Agreement for Compensation

(If an employer and employee enter into an agreement, the employer must meet certain requirements not later than 21 days from the date the employer had notice or knowledge of the disability)

LIBC-336
Supplemental Agreement

(Post-claim acceptance form evidencing employee change in status, either as a return-to-work, or reinstatement, if work is stopped)

LIBC-337
Agreement to Stop Weekly Workers’ Compensation Payments (Final Receipt)

(Terminates weekly benefits)

LIBC-340
Employer’s Report of Injury

(When an employee injury is reported to the employer)

LIBC-344
Answer to Claim Petition

(An employer’s answer to a petition for benefits)

LIBC-374
Statement of Wages

(Provides a basis to calculate pre-injury average weekly wage and compensation payable rate)

LIBC-494C
Notice of Compensation Payable

(Employee claim being accepted with injury and wage rates identified)

LIBC-495
Notice of Compensation Denial

(Employee claim being denied, requiring basis be identified)

LIBC-496
Physician’s Affidavit of Recovery

(Attesting to full recovery post-injury)

LIBC-497
Notice of Temporary Compensation Payable

(Temporary compensation benefits are payable for ninety (90) days without admission of liability as to injury or disability)

LIBC-501
Notice Stopping Temporary Compensation

(Required to be filed before expiration of ninety (90) day temporary compensation period)

LIBC-502
Utilization Review

(Challenge to reasonableness and necessity of medical care)

LIBC-601
Notification of Suspension/Modification

(Used to suspend or modify wage loss benefits within 7 days of return to work)

LIBC-751
Compromise & Release Agreement

(Document used to settle workers’ compensation claims, subject to approval by WCJ)

LIBC-755
Notice of Ability to Return to Work

(A form advising the employee that they are medically released to return to work); (with mandatory issuance prior to any employer job offer being extended)

LIBC-757

For 110 years, Powell Law has litigated Pennsylvania workers compensation actions. Consult the experienced attorneys at Powell Law. Contact us online or call (570) 961-0777. You don’t pay unless we win.

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