Free LIBC-500 REV 6-04.indd - Pennsylvania

BUREAU OF WORKERS' COMPENSATION 1171 SOUTH CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501
717-772-0621 www.dli.state.pa.us

REMEMBER: IT IS IMPORTANT TO TELL YOUR EMPLOYER ABOUT YOUR INJURY
THE NAME, ADDRESS AND TELEPHONE NUMBER OF YOUR EMPLOYER'S WORKERS' COMPENSATION INSURANCE COMPANY, THIRD-PARTY ADMINISTRATOR (TPA), OR PERSON HANDLING WORKERS' COMPENSATION CLAIMS FOR YOUR COMPANY, ARE CONTAINED BELOW. EMPLOYER NAME:__________________________________ DATE POSTED: ____________________ IF INSURED: (Complete all applicable spaces) NAME OF INSURANCE COMPANY: ___________________________________________ ADDRESS: ________________________________ ___________________________________________ TELEPHONE NUMBER: _____________________ INSURER'S BUREAU CODE: ____ ____ ____ ____ IF SOMEONE OTHER THAN INSURER IS HANDLING CLAIMS: (Complete all applicable spaces) NAME OF TPA (Claims administrator): __________________________________________ ADDRESS: _______________________________ __________________________________________ TELEPHONE NUMBER:_____________________

IF SELF-INSURED: (Complete all applicable spaces) NAME OF PERSON HANDLING CLAIMS AT THE SELF-INSURED ________________________ ___________________________________________ ADDRESS: _________________________________ ___________________________________________ TELEPHONE NUMBER: _____________________

IF SOMEONE OTHER THAN SELF-INSURER IS HANDLING CLAIMS: (Complete all applicable spaces) NAME OF TPA (Claims administrator): __________________________________________ __________________________________________ ADDRESS: ________________________________ __________________________________________ TELEPHONE NUMBER:_____________________

SELF-INSURED BUREAU CODE: ____ ____ ____ ____
Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program

LIBC-500 REV 6-04