EMPLOYER DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION NOTICE OF ABILITY002 TO RETURN TO WORK002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone DATE OF NOTICE - - MM DD YYYY DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY Name Address Address City/Town State ZIP County Telephone FEIN 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 # Section 306(b)(3) of the Pennsylvania Workers222 Compensation Act requires insurers to notify the employee when they receive medical evidence indicating the ability to return to work in some capacity. Receipt of medical evidence indicates your present physical condition or change of condition is: Attached are all documents supporting these allegations. YOU SHOULD ALSO KNOW You have an obligation to look for available employment. You have the right to consult with an attorney in order to obtain evidence to challenge the insurer222s contributions. Auxiliary aids and services are available upon request to individuals with disabilities. Employer Information Claims Information Services Email Services Hearing Impaired *757* Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com