DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION APPEAL BOARD APPEAL FROM JUDGE222S002 FINDINGS OF FACT AND002 CONCLUSIONS OF LAW002 RULES FOR APPEAL TO THE WORKERS222 COMPENSATION APPEAL BOARD002 FROM DECISION OF JUDGE002 Workers222 Compensation Act Section 423 provides a period of 20 days after notice of a Judge222s decision to take an appeal from that decision to the Worker222s Compensation Appeal Board. This 20-day period is computed from but does not include the circulation date set forth on the Judge222s decision by stamped and addressed) or is entered into the Workers222 Compensation Automation and Integration parties to the appeal indicate that no oral argument is requested or that it is waived. CITY CLAIMANT ADDRESS STATE ZIP CODE Date: Petition Type: Circulation Date: Dispute Number: VS DEFENDANT INSURANCE CARRIER ADDRESS ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE TO THE WORKERS222 COMPENSATION APPEAL BOARD, HARRISBURG, PENNSYLVANIA: I hereby appeal from the decision of Judge and allege the A copy of the Judge222s decision is attached. LICB-25/26 01-18 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com I hereby appeal from the decision of Judge and specify not conform to the provisions of the Workers222 Compensation Act or the Occupational Disease Act. A copy of the Judge222s decision is attached. Please enter my appearance for appellant: NAME NAME OF PARTY TAKING APPEAL ADDRESS APPEAL INSTRUCTIONS APPEAL SHOULD BE FILED IN AN ORIGINAL AND TWO (2) COPIES. A COPY OF JUDGE222S DECISION WITH THE DECISION RENDERED COVER LETTER CITY STATE ZIP CODE MUST BE ATTACHED TO ORIGINAL APPEAL ONLY. PROOF OF SERVICE MUST BE COMPLETED. PROOF OF SERVICE to the parties and Judge in the manner indicated below. Date: By: Signature Department of Labor & Industry | Workers222 Compensation Appeal Board 002003ra-li-wcab@pa.gov | www.dli.pa.gov002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 LICB-25/26 01-18 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com