Free 25841-LIBC-375 (Page 1) - Pennsylvania


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Date: September 27, 2002
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State: Pennsylvania
Category: Workers Compensation
Word Count: 650 Words, 4,003 Characters
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http://www.dli.state.pa.us/landi/lib/landi/pdf/bwc/libc-375.pdf

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EMPLOYEE SOCIAL SECURITY NUMBER 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

CLAIM PETITION FOR ADDITIONAL COMPENSATION FROM THE SUBSEQUENT INJURY FUND PURSUANT TO SECTION 306.1 OF THE WORKERS' COMPENSATION ACT

DATE OF INJURY

DAY YEAR

MONTH

PA BWC CLAIM NUMBER (IF KNOWN)

EMPLOYEE
First Name Last Name If Deceased - Dependent or Guardian First Name

EMPLOYER
Name Address Address City/Town County State Zip

Last Name Address Address City/Town County State Zip

Telephone

(

)

FEIN

VS. INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name Address Address City/Town State ( ) Bureau Code Zip

Telephone

(

) Telephone County Claim #

FEIN

And Commonwealth of Pennsylvania Department of Labor and Industry Harrisburg, Pennsylvania 17104-2501
An employee seeking additional compensation from the Subsequent Injury Fund should file this petition if the employee has previously incurred (through injury or otherwise) permanent partial disability, through the loss, or loss of use of, one arm, one foot, one leg or one eye, and incurs total disability through a subsequent injury, causing loss, or loss of use of, another hand, arm, foot, leg or eye. 1. Date of first (prior) loss, or loss of use of, one hand, arm, foot, leg or eye, resulting in permanent partial disability.
MONTH DAY YEAR

-

-

2. Complete description of first (prior) loss or loss of use.

a. Was this loss or loss of use work-related?

Yes

No

If Yes, name and address of employer:

3. Date of second (subsequent) loss, or loss of use of, another hand, arm, foot, leg or eye, resulting in total disability.
MONTH DAY YEAR

-

-

LIBC-375 4-02

(OVER)

4. Complete description of second (subsequent) loss or loss of use injury.

a. Was this loss or loss of use injury work-related?

Yes

No

If Yes, name and address of employer:

5. Is there pending workers' compensation litigation or a previous Workers' Compensation Judge's decision regarding the second (subsequent) loss or loss of use injury? Yes No
MONTH DAY YEAR

a. If Yes, when was the claim petition filed?

-

-

b. If a Workers' Compensation Judge's decision was rendered, what was the circulation date of the decision?
MONTH DAY YEAR

-

Yes No

c. Was there an award of benefits for a specific loss or loss of use? i. If Yes, how many weeks of benefits were awarded?

ii. On what date did the specific loss award commence?
MONTH DAY YEAR

-

. More Same Hour Hour Less Day or Week Day or Week

6. What were your wages at the time of the second (subsequent) injury? $ 7. If you have returned to work since the second (subsequent) injury, are you earning than you were at the time of injury? Current earnings $ a. If Yes, what is your current average weekly wage? $

. .

8. Are you entitled to receive any other benefits by reason of your increased disability, either from any state or federal fund or agency? Yes No If Yes, please list.

PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney Name PA Attorney ID Number Firm Name Address

Date of Petition

MONTH DAY

YEAR

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

_____________________________________________________ Address City/Town Telephone ( State Zip Code

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 and may also be subject to criminal and civil penalties through Pennsylvania Act 165.
LIBC-375 4-02