Free libc-14b - Pennsylvania


File Size: 28.3 kB
Pages: 1
File Format: PDF
State: Pennsylvania
Category: Workers Compensation
Author: wzimmerman
Word Count: 353 Words, 2,463 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dli.state.pa.us/landi/lib/landi/bwc/LIBC-14b.pdf

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LIBC-14B REV 7-02 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501

EMPLOYE'S AFFIDAVIT AND WAIVER OF WORKER'S COMPENSATION BENEFITS AND STATEMENT OF RELIGIOUS SECT
(To be filed with the 304.2 Application for Religious Exception)

EMPLOYE

EMPLOYER

STREET ADDRESS

STREET ADDRESS ZIP CODE

CITY/TOWN

STATE

CITY/TOWN

STATE

ZIP CODE

EMPLOYE SOCIAL SECURITY NUMBER

WAIVER OF WORKERS' COMPENSATION AND AFFIDAVIT I, _______________________________ , do hereby state and affirm that I am a member of ______________
EMPLOYE

____________________________________ . Its established tenets and/or teachings conscientiously oppose
RELIGIOUS SECT OR DIVISION

member acceptance of any public or private insurance benefits which make payments in the event of death, disability, old age, retirement, or towards the cost of medical bills and provision of services for medical bills (including the benefits of any insurance system established by the Federal Social Security Act), and I adhere to said tenets and/or teachings. I am, therefore, knowingly and voluntarily waiving my rights to any benefits under the Pennsylvania Workers' Compensation Act. Subscribed and affirmed to before me this _______ day of __________________ , 20 ____
SIGNATURE OF EMPLOYE (OR PARENT OR GUARDIAN IN CASE OF MINOR NOTARY PUBLIC (SEAL)

STATEMENT OF RELIGIOUS SECT I, ____________________________________ , hereby state and affirm that I am the religious leader of__________
RELIGIOUS SECT LEADER

________________________________ , and I verify that _____________________________ is a current
RELIGIOUS SECT ABOVE-NAMED EMPLOYE

member of this sect. I state and affirm that this religious sect has established tenets and/or teachings which oppose its members' acceptance of any public or private insurance benefits which make payments in the event of death, disability, old age, retirement, or toward the cost of medical bills and provision of services for medical bills (including the benefits of any insurance system established by the Federal Social Security Act). Furthermore, I state and affirm that it is the practice, and has been for ________ for members of this sect or division to make provision for
NUMBER OF YEARS

their dependent members which, in its judgment, is reasonable in view of their general level of living.

SIGNATURE OF RELIGIOUS SECT LEADER

TITLE

DATE