Free LIBC-757.indd - 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

NOTICE OF ABILITY TO RETURN TO WORK

Social Security Number: Date of Injury
MM

/
DD

/
YYYY (IF KNOWN)

PA BWC Claim Number:

Employee
First Name _______________________________ Street 1 Last Name _________________________________________

Employer
Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County ___________________________________ Telephone (______) _______-____________________ __________ _________-_______

___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County __________ Telephone __________-_______

___________________________________________ (______) _______-_______________

FEIN _____________________________

Insurer or Third Party Administrator (if self-insured) DATE OF THIS NOTICE: ______/______/______
MM DD YYYY

Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-_____________________ County ____________________________________ Claim Number ____________________________________ __________ Bureau Code __________-_______

______________________________

FEIN ______________________________

Section 306(b)(3) of the Pennsylvania Workers' Compensation Act requires insurers to notify the employee when they receive medical evidence indicating the ability to return to work in some capacity. Receipt of medical evidence indicates your present physical condition or change of condition is: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Attached are all documents supporting these allegations. YOU SHOULD ALSO KNOW You have an obligation to look for available employment. Proof of available employment may jeopardize your right to receive ongoing benefits. You have the right to consult with an attorney in order to obtain evidence to challenge the insurer's contentions. 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-757 REV 5-04