Free 31180-LIBC 495 (Page 1) - Pennsylvania

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 DATE OF NOTICE

NOTICE OF COMPENSATION PAYABLE

DATE OF INJURY

YEAR

DAY YEAR

MONTH

MONTH DAY PA BWC CLAIM NUMBER (IF KNOWN)

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

INJURY INFORMATION
Body Part(s) affected Type of Injury Description of Injury

Check if Occupational Disease

Claim #

NOTICE TO EMPLOYER: This Notice should be clearly completed, (preferably typed) and mailed to the Bureau at the address in the upper left corner. A copy must be sent to the injured employee with the first payment of compensation. NOTICE TO EMPLOYEE: If any questions arise regarding these payments, contact the representative named at the bottom of this Notice. If you cannot resolve a problem with the employer representative, you may call the Bureau at 800-482-2383. Compensation is payable as follows: Check only if compensation for medical treatment (medical only, no loss of wages) will be paid subject to the Workers' Compensation Act. Compensation for medical treatment is payable from date of injury. For compensation for medical treatment only, you should not complete numbers 1 through 5. 1. Weekly compensation rate $
MONTH DAY

.
YEAR

2. Payments begin on 3. Date first check mailed

MONTH DAY

YEAR

Based on an average weekly wage of $ (Compensation for loss of wages is payable for first 7 days only if disability extends 14 or more days; compensation for medical treatment is payable from the date of injury.) If the date exceeds the 21-Rule, check this box and explain on back of this form.

.

-

-

4. Payments will hereafter be made: Weekly Biweekly Other (Specify): Any termination, suspension or modification of these payments must be made by agreement, final receipt, administrative or judicial determination, or as otherwise provided in the Workers' Compensation Act or Regulations of the Department. 5. If injury involves loss under Section 306(c) (except for disfigurement of the head, face or neck) and employee has returned to work, complete the following information. (a) Compensation is payable for weeks
MONTH

days for loss or loss of use of
DAY YEAR

.

(b) Employee returned to work without loss of income on (c) Healing period payable for weeks

-

-

days (Up to (b) above and subject to 7-day waiting period)

(d) Total (a) and (c) payable (e) Credit taken for disability benefits paid $

weeks

days.

.

495 0903
Phone Number ( )

Name of Claims Representative Signature of Claims Representative
LIBC-495 REV 9-03

(OVER)

LIBC-495

6. Remarks

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.