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CoMMoNWeALth of PeNNSYLVANIA DePARtMeNt of LABoR & INDUStRY BUReAU of WoRKeRS' CoMPeNSAtIoN

EMPLOYEE VERIFICATION OF EMPLOYMENT, SELF-EMPLOYMENT OR CHANGE IN PHYSICAL CONDITION
employer
Name

Social Security Number _________ - _______ - _________ Date of Injury ______/_______/_________ PA BWC Claim Number _____________________________ DAte of thIS NotICe ______/_______/_________

employee
first Name _________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/town County __________________________________________ State telephone (_______) _______ - _______________ Zip Code ________________________________________________ _________ ____________-_________ Last Name _____________________________________________

_________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/town County ____________________________________________ telephone feIN _____________________ (_______)_______-____________________________ State Zip Code ________________________________________________ _________ ____________-_________

INSTRUCTIONS TO EMPLOYEE:
Do not return this form to the Bureau of Workers' Compensation. CompleteD form must Be returneD to the party Who sent the form to you Within thirty (30) Days of your reCeipt of this form. if you Do not Complete anD return this form to the party Who sent it to you Within thirty (30) Days it may result in a suspension of your Compensation Benefits as proviDeD By seCtion 311.1(g) of the WC aCt, as Well as proseCution for frauD unDer artiCle Xi of the WC aCt. you may Be requireD to Complete anD return this form every siX (6) months.

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 _____________________ ________________________________________________ _________ ____________-_________

instruCtions to employee: Section 311.1(d) of the Workers' Compensation Act requires employees who are receiving workers' compensation, or have filed a petition to receive workers' compensation, to verify employment, self-employment, wages and changes to physical condition. 1. Are you currently employed by any employer other than the employer listed above? Yes

No

2. Are you currently self-employed? Yes

No

3. Have you been employed or self-employed at any time while receiving workers' compensation benefits? Yes

No

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4. Has your physical condition (caused by your injury) changed? Yes

No

5. Is there other information you are aware of that is relevant in determining your entitlement to, or amount of compensation? Yes No

6. Names of employers for whom you have worked since your date of injury:
Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/town State Zip Code ________________________________________________ _________ ____________-_________ Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/town State Zip Code ________________________________________________ _________ ____________-_________

Period of employment: from ______/_______/_________ to ______/_______/_________
mm dd yyyy mm dd yyyy

Period of employment: from ______/_______/_________ to ______/_______/_________
mm dd yyyy mm dd yyyy

AMoUNt of WAgeS $ ___________ . _____

AMoUNt of WAgeS $ ___________ . _____

Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/town State Zip Code ________________________________________________ _________ ____________-_________

IF SELF-EMPLOYED
From ______/_______/_________ to ______/_______/_________
mm dd yyyy mm dd yyyy

AMoUNt of WAgeS $ ___________ . _____

Period of employment: from ______/_______/_________ to ______/_______/_________
mm dd yyyy mm dd yyyy

AMoUNt of WAgeS $ ___________ . _____

I verify that this information is true and correct based upon my knowledge, information and belief. I understand false statements are subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities.

Employee:
First Name ________________________ Last Name _______________________ Signature __________________________________________________________ Date ______________________________________________________________

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-760 REV 3-07 (Page 2)