application for supersedeas fund reimbursement COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS’ COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (Toll Free) 800-482-2383 TTY 800-362-4228 Social Security Number: ____ - ___ - ______ Date of Injury: ______/______/____________ mm            dd                  yyyy PA BWC Claim Number: _________________                                               (if This application is filed on behalf of: Insurer known) Self-Insured Employer Employee Employer First Name Last Name Name _________________________________ _____________________________________________ _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town State Zip Code ________________________________________________ _________ ____________-_________ County FEIN ____________________________________________ _____________________ Telephone SEE INSTRUCTIONS ON REVERSE (_______)_______-____________________________ Insurer or Third Party Administrator (if self-insured) Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 662 0707 _________________________________________________________________________________ City/Town State Zip Code ________________________________________________ _________ ____________-_________ County FEIN ____________________________________________ _____________________ Telephone (_______)_______-____________________________ Claim Number ____________________________________________ TO THE DEPARTMENT OF LABOR AND INDUSTRY, BUREAU OF WORKERS’ COMPENSATION: As insurer/self-insurer in the above case, we herewith request reimbursement of compensation paid to claimant pursuant to Section 443 of the Pennsylvania Workers’ Compensation Act. IN SUPPORT OF THE ABOVE REQUEST, WE OFFER THE FOLLOWING FACTS: Request for supersedeas was filed on _______/_______/____________ MM      DD _______/_______/____________ MM      DD YYYY in connection with      petition or      appeal filed on for    termination     modification     suspension of compensation as of _______/_______/__________. YYYY   granted on Insurer’s/self-insurer’s request for supersedeas was   denied on MM DD MM DD outcome of the proceedings on not, in fact, payable. YYYY YYYY _______/_______/____________ as a result of which insurer/self-insurer continued payment of compensation from DD YYYY   not acted on (and therefore deemed denied) MM      _______/_______/____________ _______/_______/____________ MM DD YYYY _______/_______/___________ MM DD YYYY until the final , at which time it was determined that such compensation was Is there a potential or existing third-party action?  Yes  No If yes, list docket number ____________(if known). Insurer/self-insurer verifies that the underlying case is not on appeal, that the appeal period has expired, and there is no other litigation pending which would affect Supersedeas Fund Reimbursement. Insurer/self-insurer affirmatively states that the decision issued by ___________________________________________________________ dated LIBC-662 REV 7-07 (Page 1) (OVER) _______/_______/____________ MM DD YYYY is final. American LegalNet, Inc. www.FormsWorkflow.com INSURER/SELF-INSURER, THEREFORE, REQUESTS REIMBURSEMENT OF ITS OVERPAYMENT OF COMPENSATION AS FOLLOWS: Compensation attributable to, and subsequently paid for, _______ weeks and ________ days from to _______/_______/____________ MM          DD              YYYY _______/_______/__________ MM          DD              YYYY inclusive at $___________.____ per week for TOTAL OF $ ___________.____. During the above time period, medical expenses were incurred, and subsequently paid, for a TOTAL OF $____________.____. Proof of payment of the above averments are attached hereto. The following unusual payment circumstances, if any, are:_______________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Other matters alleged: ______________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Submitter verification Name and Title i understand that false statements herein are made subject to the penalties of 18 pa. c.s. §4904 relating to unsworn falsification to authorities. _________________________________________________________________________________ Phone Number _________________________________________________________________________________ Signature _________________________________________________________________________________ Attorney for/Representative of _________________________________________________________________________________ instructions All requests for reimbursement from the Supersedeas Fund pursuant to Article IV, Section 443, of the Pennsylvania Workers’ Compensation Act (Act) must be by application on Form LIBC-662, Application for Supersedeas Fund Reimbursement. The Application must be fully completed, including all dates requested. Applicants must verify that the parties have not filed an appeal, and that the decision is final. Any information that supports the Application, including underlying petitions and decisions, must be attached to the Application. Any information relating to a potential or existing third-party recovery (including but not limited to the third party settlement agreement), compromise and release agreement, or other matter which may affect this application, must also be attached. The claimant’s social security number, BWC Claim Number (if known) and name must be included on each attached page. Applicant also must file proof of payment, which must be attached to the Application. Proof of payment should be in the form of copies of canceled checks or computer printouts of payment records. Also, proof of payment must include dates of service for indemnity and medical expenses incurred and payee names. Failure to fully complete the Application or to attach the required supporting documentation and proof of payment will result in the Application being returned without processing. An Application may be assigned to a Workers’ Compensation Judge for a hearing and determination of eligibility for reimbursement pursuant to the Act. Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-662 REV 7-07 (Page 2) American LegalNet, Inc. www.FormsWorkflow.com