Free LIBC-362 REV 6-08.cdr - Pennsylvania

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

CLAIM PETITION FOR WORKERS' COMPENSATION

EMPLOYEE SOCIAL SECURITY NUMBER

DATE OF INJURY

YEAR

MONTH DAY PA BWC CLAIM NUMBER (IF KNOWN)

EMPLOYEE
First Name Last Name If Deceased - Dependent or Guardian First Name Last Name Address Address City/T own County Telephone ( ) State Zip

EMPLOYER
Name Address Address City/T own County Telephone ( ) FEIN State Zip

VS. INSURER or THIRD PARTY ADMINISTRATOR (if self insured)
Name Address Address City/T own Telephone ( County Claim # FEIN ) State Zip Bureau Code

1. Complete description of injury or illness including all parts of body affected. (If you are seeking additional compensation from the
Subsequent Injury Fund for total disability as a result of a previous permanent loss, or loss of use of one hand, one arm, one foot, one leg or one eye, and a subsequent injury causing loss, or loss of use of, another hand, arm, foot, leg or eye, you must also submit form LIBC-375.)

MONTH

DAY

YEAR

2. If occupational disease, give the last date of employment
MONTH DAY YEAR

.

-

and/or

last date of exposure

-

-

MONTH

DAY

YEAR

3. Give date of injury or onset of disease 4. How did the injury or disease happen?

-

-

.

5. Did injury or disease occur on employer's premises?

Yes

No Where? (Be specific.)
MONTH DAY YEAR

6. Notice of your injury or disease was served on your employer on manner:

-

-

in the following

7. What was your job title at the time of injury or disease?

362 0608
LIBC-362 REV 6-08 (Page 1)

(OVER)

8. Were you working for more than one employer at the time of your injury?

Yes

No If Yes, list additional employers:
MONTH DAY YEAR

9. Did this problem cause you to stop working? 10. Are you back to work with the same employer? 11. Are you working with another employer? Yes

Yes Yes

No If Yes, give date. No If Yes, Regular Job

-

Other Job/Give Title

No If Yes, give name and address of new employer:

12. What were your wages at the time of injury? $

.

Hour More .

Day Same Hour

or Week Less Day or Week

13. If you have returned to work since your injury or illness, are you earning than you were at the time of injury? Current earnings 14. I am seeking payment for (check all that apply): Loss of Wages
MONTH DAY YEAR

$

MONTH

DAY

YEAR

Partial disability from
MONTH

DAY

YEAR

to
MONTH

DAY

YEAR

Full disability from

-

-

to

-

-

Medical bills (give name of doctor/hospital, address, type of treatment and bill in space below). Counsel fees to be paid by the employer. Loss or loss of use of arm, hand, finger, leg, foot or toe. Disfigurement (scars) of head, face, or neck.

Loss of sight. Loss of hearing. 15.Other ___________________________________________________________ 16.Is there other pending litigation in this case? Yes No If Yes, explain below:
PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney Name PA Attorney ID Number Firm Name Address Address City/T own Telephone ( ) Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program State Zip
MONTH

Date of Petition

DAY

YEAR

A copy of this petition has been sent to the employer.

Signature Employee Attorney

NOTICE: This Petition must be filled out as fully as possible. The original must be sent to the Bureau of Workers' Compensation, 1171 South Cameron Street, Room 103, Harrisburg, PA 17104-2501. A copy must be sent by you to the employer. Information on the completion of this form may be obtained by calling the Bureau of Workers' Compensation Helpline at 800-482-2383.
Any individual filing misleading or incomplete information knowingly and with 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).
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