Notice Of Claim Against Uninsured Employer
Notice Of Claim Against Uninsured Employer Form. This is a Pennsylvania form and can be use in Workers Comp.
Tags: Notice Of Claim Against Uninsured Employer, LIBC-551, Pennsylvania Workers Comp,
EMPLOYEE SOCIAL SECURITY NUMBER COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION 1171 S.CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 TTY 800-362-4228 NOTICE OF CLAIM AGAINST UNINSURED EMPLOYER DATE OF INJURY MONTH DAY YEAR Instructions: Please complete both sides of this form and mail to the address listed above. You must also forward a copy to the Pennsylvania Uninsured Employers Guaranty Fund at P.O. Box 1774, Harrisburg, PA 17105 -1774. ou Y must complete all questions that appear in bold print or the bureau will not accept this form and will return it to you. A Claim Petition for Benefits From the Uninsured Employer and the Uninsured Employers Guaranty Fund, Form LIBC-550, may not be filed until 21 days after filing this form. EMPLOYER EMPLOYEE Name Name Address Address City/Town State Zip City/Town County Telephone State Zip County ( ) Telephone Date of Birth ( ) Owner/Contact INJURY Did the injury result in a fatality? Yes No Where did the injury occur: Street Address: City: State: Describe the incident and injury. Was the injury reported to the employer? Yes No If Yes, when? To whom? DISABILITY Occupation/Job Title List the employee’s weekly wages at the time of injury Last day worked Hours worked per week ATTACH MOST RECENT PAY STATEMENT OR CHECK TUB. /S Did the injury cause a loss of wages? Yes Has the employer been paying for lost wages? No Yes No Has the employee returned to work? Yes No If so, when? How much is the employee earning? $ per hour / day / week (circle one) For whom does the employee work? Give name, address and telephone number. MEDICAL Has the employee sought medical treatment for the work injury? Yes No Has the employer paid for medical treatment for the work injury? Yes No LIBC-551 REV 06-11 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com 551 0611 List Doctors/Medical Facilities and their addresses. (Attach additional sheets, if necessary.) The injured employee (or dependent, if the employee is deceased) must complete and sign the following authorization, which the Uninsured Employers Guaranty Fund may use to collect records relating to medical treatment that the injured or deceased employee received, and to collect wage information from the injured or deceased employee’s current or previous employer(s). AUTHORIZATION TO RELEASE INFORMATION / VERIFICATION OF INFORMATION To Whom It May Concern: By signing below, I hereby request and authorize you to furnish, to the Pennsylvania Uninsured Employers Guaranty Fund or its representative(s), any and all information you have concerning the above-named employee with respect to any illness or injury, medical history, consultation, treatment, including x-rays, as well as copies of all hospital or medical records, military records or other government records. I further request and authorize employers to furnish complete information concerning wages, commissions and the like. By signing below, I attest that I am the employee identified above, or that I am the deceased employee’s dependent authorized to request the release of such records, and that I am pursuing a claim for benefits under the Pennsylvania Workers’ Compensation Act. A photocopy of this authorization shall be considered as effective and valid as the original authorization. VERIFICATION By signing below, I verify that all information submitted on this form is, to the best of my knowledge, information and belief, true, complete and correct. I understand that any individual who knowingly and with the intent to defraud, files misleading or incomplete information, is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to civil and criminal penalties, including prosecutions under 18 Pa. C.S.A. §4903 (relating to false swearing). Employee or Dependent Signature: Print Name: Address: Phone: Dated: Relationship to deceased employee, if applicable: Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-551 REV 06-11 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com