002 002 002 002002002002 DEFENDANT222S ANSWER TO DEPARTMENT OF LABOR & INDUSTRY CLAIM PETITION UNDERWORKERS222 COMPENSATION OFFICE OF ADJUDICATION PA WORKERS222 COMPENSATION ACT 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 INJURY INFORMATION Provide the following information if Employer has accepted liability for this injury: Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN VS. INSURER, FUND 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 # 223FUND224 SHALL MEAN THE UNINSURED EMPLOYERS GUARANTY FUND, SUBSEQUENT INJURY FUND, SELF-INSURANCE GUARANTY FUND OR PRE-SELF-INSURANCE GUARANTY FUND. TO YOUR HONORABLE JUDGE: in direct response to corresponding numbered allegations asserted in the claim petition.) American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 002 As a matter of further defense, the defendant states the following: PLEASE ENTER MY APPEARANCE FOR DEFENDANT: Attorney222s name PA Attorney ID number Firm name MM DD YYYY Address -- Address City/Town State ZIP Telephone Attorney222s signature Attorney222s name (typed/printed) Defendant222s signature Defendant222s name (typed/printed) NServices. Services *374*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com