en-USLIBC-118 11-18 (Page 1) 1. þ Claimant information þ þ First name: þ Last name: þ Address: þ en-USAddress: þ City: State: Zip: 2. þ Social Security number: þ en-US 3. þ Date of injury: þ en-US 4. þ Date of birth: 5. þ PA BWC claim number, if known: þ 6. þ Name and address of defaulted self-insured employer: 0 þ en-USName: þ Address: þ en-USAddress: þ City: State: Zip: en-US þ en-US en-USen-US0en-US þ en-US en-US0 þ en-US0 þ þ þ þ Name of Employer: þ Address: þ en-US0 þ City: State: Zip: þ þ Date employment started þ 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) þ þ þ þ Date employment started þ þ en-US þ en-US þ þ en-US þ 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 þ en-US þ þ þ þ en-US þ in whole or part, insurance other than workers222 compensation or by a federal, state or en-US þ en-US þ 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 þ en-US þ þ If yes, please explain: en-US00en-US0en-US0en-US0en-US0 þ en-US þ en-US þ þ If yes, please explain: en-US00en-US0en-US0en-US0en-US0 þ þ þ þ þ þ þ þ þ þ þ þ en-US þ þ þ þ þ þ þ þ þ þ þ þ þ þ en-US þ þ þ þ þ þ þ þ þ þ þ en-US þ þ þ þ þ þ þ þ þ þ þ þ þ en-US þ þ þ þ þ þ þ þ þ en-US þ þ þ þ þ þ þ þ þ þ þ þ þ þ en-US þ þ þ þ þ þ þ þ þ þ þ þ þ en-US þ þ þ þ þ þ Claimant: þ Print full name þ þ Date of application þ þ þ þ þ þ þ þ þ þ þ þ en-US þ þ 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