Free LIBC-377 REV 11-04.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

ANSWER TO PETITION TO:

Social Security Number: Date of Injury
MM

/
DD

/
YYYY (IF KNOWN)

PA BWC Claim Number:

Employee
First Name _______________________________ Street 1 Last Name _________________________________________

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

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

___________________________________________ (______) _______-_______________

FEIN ______________________________

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 __________-_______

______________________________

FEIN ______________________________

TO YOUR HONORABLE JUDGE: In answer to the petition for consideration: c c c c Review Medical Treatment and/or Billing Modify Compensation Benefits Review Compensation Benefits Set Aside Final Receipt c c c Terminate Compensation Benefits Suspend Compensation Benefits Reinstate Compensation Benefits

In the above case, the Respondent respectfully pleads as follows: (Answer in numberical order in response to corresponding numbers on petition.) ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ NOTICE: This answer should be clearly completed (preferably typed) and original mailed directly to the office of the Judge to whom the case is assigned. Answers must be filed within 20 days. Every fact alleged in the claim petition not specifically denied by this answer shall be deemed to be admitted. (OVER)
LIBC-377 REV 11-04 (Page 1)

Compensation Presently Payable Under:

c Notice of Compensation Payable c Supplemental Agreement

c Agreement c Award

(I) (we) submit the following facts for your consideration:

(I) (we) further submit for your consideration the following additional facts:

For the above reasons, (I) (we) request that your Honorable Judge ________________________________________ the said petition in the captioned case.

Respondent
First Name __________________________ Signature Last Name _______________________________________

PLEASE ENTER MY APPEARANCE FOR RESPONDENT: Attorney
First Name _____________________________ Firm Name Last Name ___________________________________________

____________________________________________________________________

___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-_________________ __________ __________-_______ PA Attorney ID Number ______________________________

Date: _________/____________/_____________
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Attorney
Signature ____________________________________________________________________

Date: _________/____________/_____________
MM DD YYYY

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-377 REV 11-04 (Page 2)