Employers Insurance Information Sheet
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Employers Insurance Information Sheet Form. This is a Pennsylvania form and can be use in Workers Comp.
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Tags: Employers Insurance Information Sheet, LIBC-500, Pennsylvania Workers Comp,
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION REMEMBER: IT IS IMPORTANT TO TELL YOUR EMPLOYER 002ABOUT YOUR INJURY002 Employer Name: IF INSURED: Date Posted: IF SOMEONE OTHER THAN INSURER IS HANDLING CLAIMS: IF SELF-INSURED IF SOMEONE OTHER THAN SELF-INSURER IS HANDLING CLAIMS: Employer Information Claims Information Services Email Services Hearing Impaired *500*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com
