Free LIBC-551 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

NOTICE OF CLAIM AGAINST UNINSURED EMPLOYER

DATE OF INJURY

DAY YEAR

MONTH

Instructions: Please complete both sides of this form and mail to the address listed above. You must also forward a copy to the Pennsylvania Uninsured Employer Guaranty Fund at P.O. Box 1774, Harrisburg, PA 17105-1774. You must complete all questions that appear in bold print, or the Bureau will not accept this form and will return to you. You may file a Claim Petition for Benefits from the Uninsured Employer Guaranty Fund and Uninsured Employer, Form LIBC-550, at least 21 days after filing this form.
EMPLOYEE
Name Address

EMPLOYER
Name Address

City/T own County Telephone ( Date of Birth )

State

Zip

City/T own County Telephone ( Owner/Contact )

State

Zip

FEIN

I am the injured employee.

Yes

No Yes No

I am the injured employee's dependent, and I am seeking benefits relating to a fatal injury. INJURY Did the injury occur in the course of employment with the Employer identified above? Was the injury reported to the Employer? Describe the incident and injury. Yes No

Yes

No

If Yes, when? _____________________________________

DISABILITY Occupation/Job Title Did the employee sign a contract of employment with the Employer identified above? Last Day Worked ____________________ Yes No

Hours worked per week ____________________ Attach most recent pay stub.

List the employee's wages $___________ per hour / day / week (circle one) Did the injury cause a loss of wages? Yes No Yes No

Has the employer been paying for lost wages?

Yes No Has the employee returned to work? How much is the employee earning? $_______________ per hour / day / week (circle one) For whom does the employee work? Give name, address and telephone number.

MEDICAL Has the employee sought medical treatment for the work injury? Has the employer paid for medical treatment for the work injury?

Yes Yes

No No

551 0107

LIBC-551 1-07 (Page 1)

(OVER)

List Doctors/Medical Facility and their addresses. (Attach additional sheets, if necessary.)

The injured employee (or dependent, if the employee is deceased) must complete and sign the following authorization, which the Uninsured Employer Guaranty Fund may use to collect records relating to medical treatment that the injured or deceased employee received, and to collect wage information from the injured or deceased employee's current or previous employer(s).
AUTHORIZATION TO RELEASE INFORMATION / VERIFICATION OF INFORMATION To Whom It May Concern: By signing below, I hereby request and authorize you to furnish, to the Pennsylvania Uninsured Employer Guaranty Fund or its representative(s), any and all information you have concerning the above-named employee with respect to any illness or injury, medical history, consultation, treatment, including x-rays, as well as copies of all hospital or medical records, military records or other government records. I further request and authorize employers to furnish complete information concerning wages, commissions, and the like. By signing below, I attest that I am the employee identified above, or that I am the deceased employee's dependent authorized to request the release of such records, and that I am pursuing a claim for benefits under the Pennsylvania Workers' Compensation Act. A photocopy of this authorization shall be considered as effective and valid as the original authorization. VERIFICATION By signing below, I verify that all information submitted on this form is, to the best of my knowledge, information and belief, true, complete and correct. I understand that any individual who knowingly and with the intent to defraud, files misleading or incomplete information, is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act, and may also be subject to civil and criminal penalties, including prosecutions under 18 Pa. C.S.A. § 4903 (relating to False Swearing). Signed: Address: ____________________________________ ____________________________________ ____________________________________ ____________________________________ Phone: ____________________________________ Relationship to deceased employee, if applicable: ______________________________________________
Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program

Dated _______________________________

Print Name: ____________________________________

LIBC-551 1-07 (Page 2)