Free LIBC-396 REV 3-04.indd - Pennsylvania


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State: Pennsylvania
Category: Workers Compensation
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http://www.dli.state.pa.us/landi/lib/landi/bwc/LIBC-396.pdf

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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

OCCUPATIONAL DISEASE CLAIM PETITION

Social Security Number: ________ - _______ - _________

$125.00 MONTHLY COMPENSATION PA BWC Claim Number: ____________________________ (IF KNOWN) FOR DISABILITY UNDER SECTION 301(i) ONLY

Employee
First Name _________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town County __________________________________________ State Telephone (_______) _______ - _______________ Zip Code ________________________________________________ _________ ____________-_________ Last Name _____________________________________________

vs.

Commonwealth of Pennsylvania Department of Labor and Industry Harrisburg, Pennsylvania 17104-2501

1. My last date of employment or self-employment in any occupation was ______/______/____________ .
MM DD YYYY

2. I became totally disabled on ______/______/____________ as a result of:
MM DD YYYY

L Coal Worker's Pneumoconiosis

L Silicosis

L Anthraco-Silicosis

L Asbestosis

3. My total disability is a result of employment in a hazardous occupation having a L Coal hazard L Asbestos hazard L Silica hazard. 4. I was employed in the Commonwealth of Pennsylvania at least two years preceding the above date of disability, as follows: (List all employment in the hazardous occupation.)
NAME OF EMPLOYER IN PENNSYLVANIA ADDRESS DATES OF EMPLOYMENT FROM TO
(MM/DD/YYYY) (MM/DD/YYYY)

_________________________________________ _________________________________________ _________________________________________ _________________________________________

______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________

______/______/___________ ______/______/___________ ______/______/___________ ______/______/___________

______/______/___________ ______/______/___________ ______/______/___________ ______/______/___________

5. If you have filed a claim previously under the Occupational Disease Act or the Workers' Compensation Act, complete the following: (a) Date of filing:
______/______/___________
MM DD YYYY

(b) Claim Petition: L Pending L Dismissed L Withdrawn (c) Claim Filed Under: L Occupational Disease Act L Workers' Compensation Act

6. I L have L have not

filed for benefits under the Federal Health and Coal Mine Safety Act of 1969.

(OVER)
LIBC-396 REV 3-04

Therefore, I hereby petition the Department of Labor and Industry to award compensation to me at the rate of $125.00 per month under the provisions of Section 301(i) of the Occupational Disease Act. DATE OF THIS NOTICE:
______/______/___________
MM DD YYYY

PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney
Name _________________________________________________________________________________ Firm Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town State Zip Code ________________________________________________ _________ ____________-_________ Telephone PA Attorney ID Number (_______) _______-___________________________ _________________________________

Petitioner
First Name _________________________________ Last Name _____________________________________________

_________________________________________________________________________________ Signature

INSTRUCTIONS TO CLAIMANT Failure to comply with these instructions will necessitate the return of your petition. Employee must sign this document. Attach two recent photographs. Place your signature and Social Security Number on the reverse side of each photograph.

NOTICE: Petition should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left corner on the front. 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-396 REV 3-04