NOTICE OF CLAIM AGAINSTDEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION UNINSURED EMPLOYER EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY WCAIS CLAIM NUMBER -- -- MM DD YYYY www.WCAIS.pa.gov. If EMPLOYEE EMPLOYER First name Last name Date of birth Address Address City/Town County State ZIP Telephone Name Address Address City/Town County Telephone Owner/Contact State ZIP FEIN Injury 002At what address did the injury occur: 002City:002 State: ZIP: Describe the incident and injury, include body parts affected or the cause of death: Was the injury reported to the employer? Yes No If yes, the two questions below MUST be answered: If yes, when? To whom? Time of injury: AM PM Did the injury result in a fatality? Yes No If the injury resulted in a fatality, provide the following dependent, guardian, executor, or estate information: Name Address -- Telephone Relationship Disability 002Occupation/Job Title: 002List the employee222s gross weekly wages at the time of injury: Last day worked002 Hours worked per week:MM DD YYYY Did the injury cause a loss of wages? Yes No Has the employer been paying for lost wages? Yes No ATTACH MOST RECENT PAY STATEMENT OR CHECK/STUB OR OTHER PROOF OF WAGES American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 002 002 002 002 Has the employee returned to work? Yes No If yes, the four quest io ns below MUST be answered: Date of return: Is the employment with the same employer Yes No Employer information: Medical002 Has the employee sought medical treatment for the work injury?002 Yes No Has the employer paid for medical treatment for the work injury? Yes No List Doctors/Medical Facilities and their addresses:VERIFICATION By signing below, I verify that all information submitted on this form is, to the best of my knowledge, information and belief, incomplete information is in violation of Section 1102 of the Pennsylvania Workers222 Compensation Act, 77 P.S. 2471039.2, and may also be subject to civil and criminal penalties, including prosecutions under 18 Pa. C.S.A. 2474903 (relating to false swearing). PLEASE ENTER MY APPEARANCEAttorney222s name:002 PA Attorney ID number:002 Firm name:002 Address: Address: Date of Notice -- City/Town: State: Zip: MM DD YYYYTelephone: ATTORNEY222S/EMPLOYEE222S, IF UNREPRESENTED, SIGNATURE TELEPHONE DATE 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 employee222s current or previous employer(s). AUTHORIZATION TO RELEASE INFORMATION/VERIFICATION OR INFORMATION To Whom It May Concern: medical history, consultation, treatment, including x-rays, as well as copies of all hospital or medical records, military records, or other government records. Signature Date Workers222 Compensation Employer Information Claims Information Services Hearing Impaired WCOAResourceCenter@pa.gov *551*Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com