Commutation Of Compensation
Commutation Of Compensation Form. This is a Pennsylvania form and can be use in Workers Comp.
Tags: Commutation Of Compensation, LIBC-498, Pennsylvania Workers Comp,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 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 Social Security Number: : COMMUTATION OF Plaintiff(s) COMPENSATION Calendar No. Date of Injury: : DD YYYY (IF KNOWN) : Employee Employer Name Last Name Street 1 : Street 1 First Name City/Town MM JUDICIAL SUBPOENA PA BWC Claim Number: -against- Street 2 Index No. : Street 2 Defendant(s) : . . . . . . . . . . . . . . . . . . . . . .State . . . .Zip Code . . . . . . . . . . . . . . . City/Town. . . .. .... .... County Telephone State Zip Code County THE PEOPLE OF THE STATE OF NEW YORK TO Telephone FEIN Insurer or Third Party Administrator (if self-insured) Name Street 1 GREETINGS: Street 2 City/Town State Zip attend before WE COMMAND 1297-1 that all business and excuses being laid aside, you and each of you Code 498 YOU, , the Honorable at the Court Telephone Bureau Code located at County of in room , on the day of , 20 County , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Claim Number FEIN A copy of this notice offailure to comply with this subpoena is punishable as a contempt offull payment of compensation to Your Commutation of Compensation is to be sent to the employee with court and will make you liable commuted,partythe original behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a and on whose filed with the Bureau. the result of your failure to comply. Pursuant to Section 412 of the Pennsylvania Workers' Compensation Act, future installments of compensation payable to the above employee not being in excess of 52 weeks, the employer/insurer indicated above hereby advises the above Witness, Honorable one of the employee of its intent to immediately pay in one sum such future installments without,discount. Justices of the Court in Compensation for this injury, County, day of , 20 , is presently payable under NATURE OF INJURY Notice of Compensation Payable or Agreement for Compensation paid to date of this notice: Compensation due in future: $ weeks weeks weeks to be paid in one sum without discount. DATE OF THIS NOTICE: MM Employer DD days. (Attorney must sign above and type name below) days. days @ $ per week for a total of Attorney(s) for YYYY Authorized Agent for Insurer or TPA (if self-insured) First Name Last Name Signature First Name Last Name Office and P.O. Address Signature Telephone No.: Facsimile No.: Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 E-Mail Address: of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Mobile Tel. No.: Pennsylvania Act 165 of 1994. LIBC-498 REV 12-97 American LegalNet, Inc. www.USCourtForms.com