Free LIBC-550 REV 1-07.cdr - Pennsylvania

EMPLOYEE SOCIAL SECURITY NUMBER
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

CLAIM PETITION FOR BENEFITS FROM THE UNINSURED EMPLOYER GUARANTY FUND AND UNINSURED EMPLOYER

DATE OF INJURY

DAY YEAR

MONTH

PA BWC CLAIM NUMBER (IF KNOWN)

EMPLOYEE
First Name Last Name If Deceased - Dependent or Guardian First Name Last Name Address Address City/T own County Telephone ( ) State Zip

EMPLOYER
Name Address Address City/T own State Zip

VS. County
Telephone ( ) FEIN

AND

Pennsylvania Uninsured Employer Guaranty Fund P.O. Box 1774 Harrisburg, PA 17105-1774

Employees should file this Petition if they are seeking an award against the Uninsured Employer Guaranty Fund because their employer did not maintain workers' compensation insurance coverage and was not approved as a self-insurer at the time of the alleged injury. NOTE: You may not file this petition until at least 21 days after you filed a Notice of Claim Against Uninsured Employer, Form LIBC-551. 1. Have you filed a Notice of Claim Against Uninsured Employer, Form LIBC-551? 2. Complete description of injury or illness including all parts of body affected. Yes No

MONTH

DAY

YEAR

3. If occupational disease, give the last date of employment
MONTH DAY YEAR

-

-

and/or

last date of exposure

-

MONTH DAY YEAR

4. Give date of injury or onset of disease 5. How did the injury or disease occur?

-

-

6. Did injury or disease occur on employer's premises?

Yes

No Where? (Be specific.)

MONTH

DAY

YEAR

7. Notice of your injury or disease was served on your employer on following manner: 8. What was your job title at the time of injury or disease?

-

-

in the

550 0107

LIBC-550 1-07 (Page 1)

(OVER)

9. Were you working for more than one employer at the time of your injury?

Yes

No If Yes, list additional employers:

MONTH

DAY

YEAR

10. Did this problem cause you to stop working? 11. Are you back to work with the same employer? 12. Are you working with another employer? Yes

Yes Yes

No If Yes, give date. No If Yes, Regular Job

-

Other Job / Give Title.

No If Yes, give name and address of new employer:

13. What were your wages at the time of injury? $

. .
to
MONTH

Hour More

Day Same Hour

or Week Less Day or Week

14. If you have returned to work since your injury or illness, are you earning than you were at the time of injury? Current earnings $ 15. I am seeking payment for (check all that apply): Loss of Wages
MONTH DAY YEAR

DAY

YEAR

Partial disability from
MONTH

DAY

YEAR

to
MONTH DAY

YEAR

Full disability from

-

-

-

-

Medical bills (give name of doctor/hospital, address, type of treatment and bill in space below).

Counsel fees to be paid by the employer . (Note: The Fund is not subject to unreasonable contest attorney fees.) Loss or loss of use of arm, hand, finger, leg, foot or toe. Disfigurement (scars) of head, face, or neck. Injury or disease resulting in death. Date of death. Loss of sight. Loss of hearing. 16. Have you filed any other Workers' Compensation Petition(s) related to this injury? If Yes, PA BWC Claim Number (if known)
PLEASE ENTER MYAPPEARANCE FOR PETITIONER:
DATE OF PETITION MONTH DAY YEAR

-

-

Yes

No

Attorney Name PA Attorney ID#
MONTH

DAY

YEAR

Name of Firm Address Address City/T own Telephone ( ) State Zip

A copy of this petition has been sent to the employer and the Fund.

Signature Employee Attorney

NOTICE: This Petition must be filled out as fully as possible. The original must be sent to the Bureau of Workers' Compensation, 1171 South Cameron Street, Room 103, Harrisburg, PA 17104-2501. You must send a copy of this Petition to the employer and Guaranty Fund, P.O. Box 1774, Harrisburg, PA 17105-1774. Information on the completion of this from may be obtained by calling the Bureau of Workers' Compensation Helpline at 800-482-2383. 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.

LIBC-550 1-07 (Page 2)

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