DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION AGREEMENT FOR COMPENSATION002 FOR DISABILITY OR002 PERMANENT INJURY002 -- -- EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone INJURY INFORMATION Check if occupational disease 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 Contact NAIC code or Insurer code Insurer/TPA claim # NOTICE: Agreement should be clearly completed, (preferably typed) and uploaded in accordance with the provisions of the EDI Implementation Guide. A copy must be sent to the employee. Wage information must be completed in accordance with the Pennsylvania Workers222 Compensation Act, and sent to the employee. DATE DISABILITY BEGAN -- MM DD YYYY The employer shall pay the employee compensation at a rate of $ per week on an average weekly wage of $ beginning . -- MM DD YYYY Compensation payable for weeks days for loss or loss of use of under Section 306(c). Compensation payable for weeks days for healing period for loss or loss of use of under Section 306(c). LIBC-336 REV 04-19 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com Further matters agreed upon: We, the undersigned, agree upon the matters represented herein by the above named employee and the above named employer. Employee222s signature -- Date of agreement MM DD YYYY (typed/printed) Telephone NOTICE TO EMPLOYEE: If temporary compensation was being paid prior to this agreement, the payment of temporary Notice of Temporary Compensation Payableemployer not set forth in this Agreement for Compensation for Disability or Permanent Injury. The payment of Employer Information Claims Information Services Hearing Impaired Email Services *336*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 LIBC-336 REV 04-19 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com