EMPLOYEE SOCIAL SECURITY NUMBER 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 NOTICE OF COMPENSATION PAYABLE DATE OF INJURY - DATE OF NOTICE - - MONTH - MONTH DAY PA BWC CLAIM NUMBER (IF KNOWN) DAY YEAR YEAR EMPLOYER EMPLOYEE First Name Name Last Name Address Address Address Address City/Town City/Town State Zip Zip County Telephone ( County Telephone ( State ) ) FEIN INSURER or THIRD PARTY ADMINISTRATOR (if self insured) INJURY INFORMATION Name Body Part(s) affected Address Type of Injury Address Description of Injury City/Town Telephone ( State ) Bureau Code Claim # Check if Occupational Disease Zip FEIN NOTICE TO EMPLOYER: This Notice should be clearly completed, (preferably typed) and mailed to the Bureau at the address in the upper left corner. A copy must be sent to the injured employee with the first payment of compensation. NOTICE TO EMPLOYEE: If any questions arise regarding these payments, contact the representative named at the bottom of this Notice. If you cannot resolve a problem with the employer representative, you may call the Bureau at 800-482-2383. Compensation is payable as follows: Check only if compensation for medical treatment (medical only, no loss of wages) will be paid subject to the Workers’ Compensation Act. Compensation for medical treatment is payable from date of injury. For compensation for medical treatment only, you should not complete numbers 1 through 5. MONTH DAY MONTH 3. Date first check mailed YEAR - - 2. Payments begin on . . 1. Weekly compensation rate $ DAY - YEAR Based on an average weekly wage of $ (Compensation for loss of wages is payable for first 7 days only if disability extends 14 or more days; compensation for medical treatment is payable from the date of injury.) - If the date exceeds the 21-Rule, check this box and explain on back of this form. 4. Payments will hereafter be made: Weekly Biweekly Other (Specify): Any termination, suspension or modification of these payments must be made by agreement, final receipt, administrative or judicial determination, or as otherwise provided in the Workers’ Compensation Act or Regulations of the Department. 5. If injury involves loss under Section 306(c) (except for disfigurement of the head, face or neck) and employee has returned to work, complete the following information. (a) Compensation is payable for weeks days for loss or loss of use of MONTH DAY . YEAR - (b) Employee returned to work without loss of income on - (c) Healing period payable for days (Up to (b) above and subject to 7-day waiting period) (d) Total (a) and (c) payable (e) Credit taken for disability benefits paid $ weeks weeks days. . Name of Claims Representative Phone Number ( Signature of Claims Representative LIBC-495 REV 9-03 495 0903 (OVER) ) LIBC-495 6. Remarks 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.