Free LIBC-363 REV 6-04 - Pennsylvania


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Pages: 2
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State: Pennsylvania
Category: Workers Compensation
Word Count: 531 Words, 7,172 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dli.state.pa.us/landi/lib/landi/bwc/LIBC-363.pdf

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Preview LIBC-363 REV 6-04
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

FATAL CLAIM PETITION FOR COMPENSATION BY DEPENDENTS OF DECEASED EMPLOYEES

Deceased's Social Security Number: Date of Injury:
MM

/
DD YYYY

-

/

PA BWC Claim Number:
(IF KNOWN)

Deceased Employee
First Name _______________________________ Last Name _________________________________________

Employer
Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code Last Name _________________________________________ __________________________________________ County _________________________________ Telephone (______) _______-_______________ __________ __________-_______

Date of Birth ______/______/__________ MM DD YYYY

Date of Death ______/______/__________ MM DD YYYY

Dependent
First Name _______________________________ Street 1

FEIN ______________________________

___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County __________ Telephone __________-_______

VS.
Insurer or Third Party Administrator (if self-insured)
Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-_______________ County ______________________________ Claim Number ______________________________ __________ Bureau Code __________-_______

___________________________________________ (______) _______-_______________

Injury
Description of Injury and Cause of Death ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

______________________________

___________________________________________________________________________ ____________________________________________ Check if Occupational Disease

FEIN ______________________________

The petitioner respectfully alleges that: 1. Business of employer _______________________________________________________________________ 2. Time of injury (hour) ______________ AM PM

3. The cause of death was ___________________________________________ as given by ________________ _________________________________________________________________________________________ 4. The deceased employee received aid from the following doctors and/or hospitals: _________________________________________________________________________________________
GIVE NAMES AND ADDRESSES. IF NONE, SO STATE.

5. Expenses of the last illness and burial amounted to $_____________.______ Amount paid by employer $_____________.______ 6. The wages of deceased at the time of accident were $_____________.____ G hour G day G week

NOTICE: Petition should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left corner. (OVER)
LIBC-363 REV 6-04 (Page 1)

7. Notice of injury and/or death was given to employer on ____/____/______ by ____________________________________
MM DD YYYY NAME OF PERSON REPORTING INJURY/DEATH

in the following manner _______________________________________________________________________________
STATE WHEN AND TO WHOM NOTICE WAS GIVEN AND IN WHAT MANNER.

8. Compensation for disability was paid to the deceased employee from ____/____/______ to ____/____/______.
MM DD YYYY MM DD YYYY

Total amount paid was $_____________.______ 9. Dependents are as follows:
NAME
_________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________

RESIDENCE
_____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________

DATE OF BIRTH
(MM/DD/YYYY) ________/________/__________ ________/________/__________ ________/________/__________ ________/________/__________ ________/________/__________

RELATIONSHIP
_____________________________ _____________________________ _____________________________ _____________________________ _____________________________

10. Their dependency is 11. Petitioner G was G is

G Total G Partial G was not G is not living with the deceased at the time of his or her death. a widow/widower of the deceased.

12. The petitioner a.

If petitioner is a widow or widower, state where ceremony was performed and give date of marriage. _______________________________________________________________________ _____/_____/______
MM DD YYYY

b.

Was marriage a common law marriage?

G Yes G No

13. Other facts which I believe to be important are _____________________________________________________________ __________________________________________________________________________________________________ WHEREFORE, the Petitioner(s) asks that the Bureau shall make an award in accordance with the Pennsylvania Workers' Compensation Act. DATE OF THIS NOTICE: ____/____/_______
MM DD YYYY

PLEASE ENTER MY APPEARANCE FOR PETITIONER:

Attorney
Name ___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2

A copy of this petition has been sent to the defendant. Signature _________________________________________________ Dependent
First Name _______________________________ Signature Last Name ______________________________________________

___________________________________________________________________________ City/Town State Zip Code _______________________________________ Telephone (______) _______-________________________ _________ _____________-_______ PA Attorney ID Number ________________________________

________________________________________________________________________________

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 and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994.
Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program
LIBC-363 REV 6-04 (Page 2)