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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

EMPLOYEE SOCIAL SECURITY NUMBER

FINAL STATEMENT OF ACCOUNT OF COMPENSATION PAID

DATE OF INJURY

MONTH DAY PA BWC CLAIM NUMBER (IF KNOWN)

YEAR

EMPLOYEE
First Name Last Name Address Address City/Town County Telephone ( ) State Zip

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

INSURER or THIRD PARTY ADMINISTRATOR (if self insured)
Name Address

NOTICE: A Final Statement of Account shall be filed after the final payment of compensation.

Address City/Town Telephone ( County Claim # FEIN ) State Bureau Code Zip

This is to certify that the above named employer or insurer has paid compensation under the Pennsylvania Workers' Compensation Act in the above case as follows: Rate . . . *Additional payment periods or remarks should be indicated on the reverse side of this form. Medical Payments Indemnity Payments Other Payments TOTAL COMPENSATION PAID $ $ $ $ . . . . From Date To Date #Wks #Days Total . . .

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392A 0908

Remarks/Additional Information:

Name of Employer/Insurer Representative
DATE

Signature of Employer/Insurer Representative

Month

Day

Year

392A 0908
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).
Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program

LIBC-392A REV 9-08 (Page 2)