DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION CLAIM PETITION FOR BENEFITS002 FROM THE UNINSURED EMPLOYER002 AND THE UNINSURED EMPLOYERS002 GUARANTY FUND002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER -- -- DATE OF INJURY WCAIS CLAIM NUMBER EMPLOYEE First name Last name Date of birth If Deceased - Dependent/Guardian/Personal Representative First name Last name Address Address City/Town State ZIP County Telephone MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP VS CountyTelephone FEIN AND Pennsylvania Uninsured Employers Guaranty Fund 1171 S. Cameron St. Harrisburg, PA 17104 E 2.Complete description of injury or illness including all parts of body affected. If fatality, provide cause of death. and/or -- 3.If occupational disease, give the last date of employmentMM DD YYYY last date of exposure MM DD YYYY 4.Give date of injury or onset of disease 7.Notice of your injury or disease was served on your employer onin the following manner: MM DD YYYY -- --MM DD YYYY -- - -8. MM DD YYYY American LegalNet, Inc. www.FormsWorkFlow.com . . DATE OF BIRTH NAME ADDRESS RELATIONSHIP MM-DD-YYYY Yes No Yes No Yes No Yes No US CITIZEN Yes No Yes No Loss of Wages - - - - ongoingPartial disability from to MM DD YYYY MM DD YYYY - - - - ongoingFull disability from to MM DD YYYY MM DD YYYY 002 002 002 002 - -Injury or disease resulting in death. Date of death. MM DD YYYY Loss of sight002 Loss of hearing002 Other A copy of this petition has been sent to the PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney222s name MM DD YYYY PA attorney ID number Firm name employer and the Fund. Address --Date of petition Address SignatureCity/Town State ZIP Employee or Dependent Attorney Telephone N 844.237.6316 717.772.3702 WCOAResourceCenter@pa.gov *550*Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com