DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION CLAIM PETITION FOR 002WORKERS222 COMPENSATION EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth If deceased - Dependent/Guardian/Personal Representative First name Last name Address Address City/Town State ZIP County Telephone DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN VS. INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim # 1.Complete description of injury or illness including all parts of body affected. (If you are seeking additional compensation from the Subsequent Injury Fund for total disability as a result of a previous permanent loss, or loss of use of one hand, one arm, one foot, one leg or one eye, and a subsequent injury causing loss, or loss of use of, another hand, arm, foot, leg or eye, you must also submit from LIBC-375). 2.If occupational disease, give the last date of employment and/or last date of exposure with this employer. 3.Give date of injury or onset of disease . --MM DD YYYY --MM DD YYYY --MM DD YYYY 4.How did the injury or disease happen? Yes No Where? 5.Did injury or disease occur on employer222s premises?6.Notice of your injury or disease was served on your employer onin the following manner:MM DD YYYY 7.What was your job title at the time of injury or disease? Yes No If yes, list additional employers: 8.Were you working for more than one employer at the time of your injury? - - Yes No If yes, give date .9.Did this problem cause you to stop working?MM DD YYYY 10.Are you back to work with the same employer? Yes No If yes, Regular job Other job/give title -- American LegalNet, Inc. www.FormsWorkFlow.com 002 002002 002 002 11.003Are you back to work with another employer? Yes No If yes, give name and address of new employer: .12.003 What were your wages at the time of injury? $ Hour Day Week 13.003 If you have returned to work since your injury or illness, are you earning than you were at the time of injury? Current earnings $ . 14.003I am seeking payment for (check all that apply): Loss of wages More Same Less Hour Day Week - - - -Partial disability from thru (date disability ends) or ongoing. MM DD YYYY MM DD YYYY - - - -Full disability from thru (date disability ends) or ongoing. MM DD YYYY MM DD YYYY Medical bills (Attach additional sheet giving name of health care provider, address, type of treatment and amount of bill). Counsel fees to be paid by the employer. 002002Loss of sight. 002Loss of hearing. 00215.003Other16.003Is there other pending litigation in this case? Yes No If yes, explain below: PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney222s name PA Attorney ID number MM DD YYYY Firm name -- Date of petition Address Address City/Town State ZIP Telephone Attorney222s signature N77 P.S. 2471039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. 2474117 (relating to insurance fraud). Employer Information Claims Information Services Email Services toll-free inside PA: 800.482.2383 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 Hearing Impaired *362*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com