Pennsylvania Workers’ Compensation Legal Forms

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:

• It Is Important to Tell Your Employer About Your Injury

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 755    Compromise and Release Agreement by Stipulation Pursuant to Section 449 of the Workers’ Compensation Act

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