DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION DEFENDANT222S ANSWER TO CLAIM002 PETITION UNDER PENNSYLVANIA002 OCCUPATIONAL DISEASE ACT002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Date of death 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 INJURYWCAIS 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 Contact NAIC code or Insurer code Insurer/TPA claim # And Commonwealth of Pennsylvania002 Department of Labor & Industry002 Harrisburg, PA 17104-2501002 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: direct response to corresponding numbered allegations asserted in the claim petition.) American LegalNet, Inc. www.FormsWorkFlow.com As a matter of further defense, the defendant states the following: PLEASE ENTER MY APPEARANCE FOR DEFENDANT: PA Attorney ID number Firm name Address Address MM DD YYYY City/Town State ZIP Telephone (typed/printed) (typed/printed) N1010 N. Seventh St, Suite 20, Harrisburg, PA, 17102-1400. You must send a copy to all unrepresented parties and to the attorney of record for all parties which are represented by counsel. A Proof of Service must be attached. A Proof of Service is a signed statement by you verifying that you have sent a copy of the answer to Information Services. -- Employer Information Services Claims Information Services Hearing Impaired Email *364B*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com