Free LIBC-686 REV 6-04.PMD - Pennsylvania

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 TTY 800-362-4228

Social Security Number: ________ - _______ - _________

PETITION FOR PENALTIES

Date of Injury: ______/______/____________
MM DD YYYY

PA BWC Claim Number: ____________________________
(IF KNOWN)

Employee
First Name __________________________________ Street 1 ________________________________________________________________________________________ Street 2 _______________________________________________________________________________________ City/Town County __________________________________________ State Telephone (_______) _______ - __________________ Zip Code __________________________________________________ _________ ____________ - __________ Last Name ________________________________________________

Employer
Name _______________________________________________________________________________________ Street 1 _______________________________________________________________________________________ Street 2 _______________________________________________________________________________________ City/Town County ____________________________________________ Telephone (_______)_______-____________________________ FEIN _______________________ State Zip Code ________________________________________________ ___________ _____________ - __________

VS. Injury

Insurer or Third Party Administrator (if self-insured)
Name ___________________________________________________________________________________________ Street 1 ________________________________________________________________________________________ Street 2 ________________________________________________________________________________________ City/Town Telephone (_______) _______-___________________________ County ____________________________________________ Claim Number ____________________________________________ FEIN _____________________ State Zip Code Bureau Code ______________________

Description of Injury and Cause of Death ________________________________________________________________________________________ ________________________________________________________________ _________________ _______________________________________________________________ __________________ __________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ _________________________________________________________________________________________ ____________________________________________ Check if Occupational Disease

__________________________________________________ _________ _____________ - __________

L

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

Counsel for Respondent (if known)
Name _______________________________________________________________________________________ Firm Name _______________________________________________________________________________________ Street 1 _______________________________________________________________________________________ Street 2 _______________________________________________________________________________________ City/Town Telephone (_______) _______-___________________________ State Zip Code _____________________________________________________ ___________ __________ - _______ PA Attorney ID Number _________________________________

NOTICE: This petition should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left corner.

LIBC-686 REV 6-04 (Page 1)

(OVER)

1. The aforementioned Employee, or his/her Representative, ____________________________________________________, believes that the aforementioned Insurer, TPA, or Self-insured Employer has violated the terms of the Workers' Compensation Act and/or Regulations in the processing or payment of compensation to the Employee(s) in that: (Specify, in detail, the nature of the alleged violation(s) and the Section of the Law/Regulation which applies. Attach an additional sheet, if necessary.)

2. Further, the Employee requests that the Insurer, TPA, or Self-insured Employer be required to pay penalties in the total amount of $__________.____, which represents ________ percentage of the compensation to which the Employee was entitled, but L not paid which was L paid late L illegally suspended for the period from
_______/_______/___________
MM DD YYYY

to

_______/_______/________
MM DD YYYY

WHEREFORE, the Employee requests that the Department of Labor and Industry require the Insurer, TPA, or Self-insured Employer to answer this Petition within twenty(20) days of service of this Petition on the adverse parties as provided for by Section 416 of the Workers' Compensation Act, and to schedule such hearings as are necessary to determine and grant the relief requested in the previously mentioned paragraphs.

DATE OF THIS NOTICE:

______/______/___________
MM DD YYYY

Petitioner
First Name _________________________________ Signature ___________________________________________________________________________________ Last Name _____________________________________________

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-686 REV 6-04 (Page 2)