en-USLIBC-118 11-18 (Page 1) 1. � Claimant information � � First name: � Last name: � Address: � en-USAddress: � City: State: Zip: 2. � Social Security number: � en-US 3. � Date of injury: � en-US 4. � Date of birth: 5. � PA BWC claim number, if known: � 6. � Name and address of defaulted self-insured employer: 0 � en-USName: � Address: � en-USAddress: � City: State: Zip: en-US � en-US en-USen-US0en-US � en-US en-US0 � en-US0 � � � � Name of Employer: � Address: � en-US0 � City: State: Zip: � � Date employment started � en-USAPPLICATION FOR BENEFITSen-USUNDER SECTION 909 OF THE en-USWORKERS222 COMPENSATION ACT DEPARTMENT OF LABOR & INDUSTRY en-USBUREAU OF WORKERS222 COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com en-USLIBC-118 11-18 (Page 2) � � � � Date employment started � � en-US � en-US � � en-US � en-USen-USAmount Receiveden-USen-USen-USUnemploymenten-UScompensationen-USen-USen-US Weeklyen-US Bi-weeklyen-US Otheren-US en-US /en-US en-US/ en-USen-US en-US / en-US en-US/ en-USen-USSocial Security en-USen-USen-USen-US Weeklyen-US Bi-weeklyen-US Otheren-US en-US /en-US en-US/ en-USen-US en-US / en-US en-US/ en-USen-USPensionen-USen-USen-US Weeklyen-US Bi-weeklyen-US Otheren-US en-US /en-US en-US/ en-US � en-US � � � � en-US � in whole or part, insurance other than workers222 compensation or by a federal, state or en-US � en-US � en-US0en-US0en-US0en-US0 American LegalNet, Inc. www.FormsWorkFlow.com en-USLIBC-118 11-18 (Page 3)en-USAuxiliary aids and services are available upon request to individuals with disabilities.en-USEqual Opportunity Employer/Program � en-US � � If yes, please explain: en-US00en-US0en-US0en-US0en-US0 � en-US � en-US � � If yes, please explain: en-US00en-US0en-US0en-US0en-US0 � � � � � � � � � � � � en-US � � � � � � � � � � � � � � en-US � � � � � � � � � � � en-US � � � � � � � � � � � � � en-US � � � � � � � � � en-US � � � � � � � � � � � � � � en-US � � � � � � � � � � � � � en-US � � � � � � Claimant: � Print full name � � Date of application � � � � � � � � � � � � en-US � � en-USPennsylvania Bureau of Workers222 Compensationen-USSelf-Insurance Divisionen-US1171 South Cameron Street, Room #324en-USen-US717-783-4476 American LegalNet, Inc. www.FormsWorkFlow.com