Free LIBC-10 REV 6-04.indd - Pennsylvania

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 TTY 800-362-4228

AUTHORIZATION FOR ALTERNATIVE DELIVERY OF COMPENSATION PAYMENTS
Employer
Name

Social Security Number: Date of Injury
MM

/
DD

/
YYYY (IF KNOWN)

PA BWC Claim Number:

Employee
Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ __________ County Telephone _____________________________________ _________-________

___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County _________________________________ Telephone (______) _______-__________________ __________ _________-_______

(________) ________-__________________

FEIN ______________________________

Insurer or Third Party Administrator (if self-insured)
Name

DATE OF AUTHORIZATION

___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code

MM

/

DD

/

YYYY

__________________________________________ Telephone (______) _______-___________________ County __________________________________ Claim Number __________________________________

__________ Bureau Code

__________-_______

______________________________

FEIN ______________________________

I, ____________________________________________________, hereby authorize and agree that the checks for the compensation
CLAIMANT NAME (PLEASE PRINT)

payments due to me shall be forwarded to me in the following designated manner: c c I will pick up my checks at (please check only one box): The employer/insurer will mail my checks to me at: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ c The employer/insurer will direct deposit my checks to the account at the financial institution supplied on the attached authorization for direct deposit. (Attach authorization for direct deposit provided by your financial institution.) c Other: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ I understand that my employer/insurer is required to mail my compensation checks to my last known address and that I am not under any obligation to authorize the method of delivery outlined above. _____________________________________________________
CLAIMANT'S NAME

c

employer office

c

insurer office

_____________________________________________________
NAME OF EMPLOYER/INSURER REPRESENTATIVE

_____________________________________________________
CLAIMANT'S SIGNATURE

_____________________________________________________
SIGNATURE OF EMPLOYER/INSURER REPRESENTATIVE

LIBC-10 REV 6-04