Notice Of Reinstatement Of Workers Compensation Benefits Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Notice Of Reinstatement Of Workers Compensation Benefits Form. This is a Pennsylvania form and can be use in Workers Comp.
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Tags: Notice Of Reinstatement Of Workers Compensation Benefits, LIBC-763, Pennsylvania Workers Comp,
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION NOTICE OF REINSTATEMENT OF002 WORKERS222 COMPENSATION002 BENEFITS002 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 THIS NOTICE: - - MM DD YYYY DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYER 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 # ATTORNEY FOR EMPLOYEE (if known) ATTORNEY FOR INSURER/EMPLOYER (if known) Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number Name Signature Address Address City/Town State ZIP Telephone FEIN A COPY OF THIS FORM AND ATTACHMENTS ARE TO BE PROVIDED TO THE EMPLOYEE AND THE EMPLOYEE222S ATTORNEY (IF KNOWN). (OVER) American LegalNet, Inc. www.FormsWorkFlow.com - - MM DD YYYY your indicated NO - OR- - - MM DD YYYY Employer Information Claims Information Services Email Services Hearing Impaired *763*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com