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Pennsylvania Workers’ Compensation Legal Forms
Helping Injured Workers Through the Complex Process of Claiming Benefits
If you have sustained an injury while in the court of your job duties, the Pennsylvania Workers’ Compensation Act allows you to collect benefits while you recover. There is a tremendous amount of paperwork and documentation that goes into making a successful claim for benefits, which is why you should always work with an experienced workers’ compensation attorney when you file your claim or seek an appeal.
Below you will find links to some of the more common documentation for making a claim. If you are self-insured, there are additional materials and steps you will take, and you should contact our firm immediately to find out what your rights are.
If you wish to file a claim for workers’ compensation in Pennsylvania, the Department of Labor & Industry recommends you read the following information:
Common Legal Forms Used in Claims for Workers’ Compensation in Pennsylvania
All titles and links come directly from the Pennsylvania Department of Labor & Industry. Some links are for informational purposes only, and cannot be printed and filled out.
LIBC 9 Medical Report Form
LIBC 10 Authorization for Alternative Delivery of Compensation Payments
LIBC 25/26 Appeal from Judge’s Findings of Fact and Conclusions of Law
LIBC 34 Petition for Commutation
LIBC 90 Electronic Data Interchange First Report of Injury
LIBC 337 Supplemental Agreement for Compensation for Disability or Permanent Injury
LIBC 338 Agreement for Compensation for Death
LIBC 339 Supplemental Agreement for Compensation for Death
LIBC 362 Claim Petition for Workers’ Compensation
LIBC 363 Fatal Claim Petition for Compensation by Dependents of Deceased Employees
LIBC 375 Claim Petition for Additional Compensation From the Subsequent Injury Fund
LIBC 376 Petition for Joinder of Additional Defendant
LIBC 377 Answer to Petition To/For
LIBC 378 Petition TO/FOR: (Check any that apply)
LIBC 380 Third Party Settlement Agreement
LIBC 392A Final Statement of Account of Compensation Paid
LIBC 396 Occupational Disease Claim Petition Monthly Compensation for Disability Under Section 301(i) Only
LIBC 480 Subpoena
LIBC 495 Notice of Compensation Payable
LIBC 496 Notice of Workers’ Compensation Denial
LIBC 497 Physician’s Affidavit of Recovery
LIBC 499 Petition for Physical Examination or Expert Interview of Employee (Section 314)
LIBC 501 Notice of Temporary Compensation Payable
LIBC 502 Notice Stopping Temporary Compensation
LIBC 504 Child Support Lien Affidavit
LIBC 550 Claim Petition for Benefits from the Uninsured Employer and the Uninsured Employers Guaranty Fund
LIBC 551 Notice of Claim Against Uninsured Employer
LIBC 552 Authorization to Release Information/Verification or Information
LIBC 604 Utilization Review Determination Face Sheet
LIBC 749 Death Claim Supplement to Compromise and Release Agreement
LIBC 750 Employee Report of Wages
LIBC 751 Notification of Suspension or Modification Pursuant to 413(c) & (d)
LIBC 753 Notice of Request for an Informal Conference
LIBC 754 Informal Conference Agreement Form
LIBC 757 Notice of Ability To Return To Work
LIBC 761 Notice of Workers’ Compensation Benefit Offset
LIBC 763 Notice of Reinstatement of Workers’ Compensation Benefits
GET A FREE CONSULTATION WITH LARRY PITT
Hurt at Work? Let Us Help You
Larry Pitt & Associates is the Philadelphia workers’ compensation law firm you can trust. We’ve been helping your friends and neighbors recover after a worksite injury for close to 40 years. If you or your family member was hurt on the job, we will fight on your behalf. To schedule your free consultation with one of our Philadelphia workers’ compensation attorneys, please call 1-888-PITT-LAW or fill out our contact form. We proudly represent clients in:
- Lehigh County
- Lancaster County
- Northampton County