DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION NOTIFICATION OF SUSPENSION002 OR MODIFICATION PURSUANT002 TO 247247 413 (c) & (d)002 --DATE OF NOTIFICATION MM DD YYYY EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY WCAIS CLAIM NUMBER -- -- EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County TelephoneINSTRUCTIONS This form must be completed, notarized and either uploaded in WCAIS or mailed to the Bureau of Workers222 Compensation (BWC), 1171 South Cameron Street, Room 103, Harrisburg, PA 17104-2501. This form must be mailed to the employee Compensation Act. 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 # -- MM DD YYYY - - than your MM DD YYYY time-of-injury earnings of $ . OR - -to work at earnings less than your time-of-injury earnings. MM DD YYYY INSURER222S AFFIDAVIT and correct to the best of my knowledge, information and belief. SUBSCRIBED AND SWORN TO (OR AFFIRMED) BEFORE ME THIS (typed/printed) DAY OF , Phone number Signature of notary NOTE TO EMPLOYEE: If you do not agree with this action and wish to challenge it, please read the instructions under EMPLOYEE CHALLENGE on the back of this form. American LegalNet, Inc. www.FormsWorkFlow.com compensation rate is based on the claimant222s present weekly earning and is calculated as follows: Subtotal EMPLOYEE CHALLENGE: If you do not agree with this action, you must challenge it within (20) days of the date you receive this notice. want to challenge. In the alternative, you may challenge by checking the box below, signing this form and mailing days from the date you received it. (if the employee has legal counsel, complete below.) Employee222s signature Attorney222s name AddressPA attorney ID# AddressCity/Town State ZIPAddress County Address TelephoneCity/Town State ZIP TelephoneEmployer Information Claims Information Services Email Services Hearing Impaired *751*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com