DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION NOTICE OF SUSPENSION FOR FAILURE TO RETURN002 FORM LIBC-760002 (EMPLOYEE VERIFICATION OF EMPLOYMENT, SELF-EMPLOYMENT OR CHANGE IN PHYSICAL CONDITION) EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone DATE OF THIS NOTICE: - - MM DD YYYY DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim #ATTORNEY FOR EMPLOYEE (if known) Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number ATTORNEY FOR INSURER/EMPLOYER (if known) Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number Name Signature Address Address City/Town State ZIP Telephone FEIN A COPY OF THIS FORM AND ATTACHMENTS ARE TO BE PROVIDED TO THE EMPLOYEE AND THE EMPLOYEE222S ATTORNEY (IF KNOWN). (OVER) American LegalNet, Inc. www.FormsWorkFlow.com -- Y MM DD YYYY due to your failure to return the form (LIBC-760) which was mailed to you on . This form was due for return to the sender within -- MM DD YYYY 30 calendar days of its receipt. Your failure to return the completed form within this time period entitles your insurer/employer Act relating to fraud. immediately to clarify this matter. promptly to stop this suspension action. Employer Information Claims Information Services Email Services Hearing Impaired *762*002 002003002003 American LegalNet, Inc. www.FormsWorkFlow.com