DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION NOTICE OF REQUEST FOR AN002 INFORMAL CONFERENCE002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County TelephoneWCOA USE ONLY Date of conference - - - - MM DD YYYY MM DD YYYY Informal conference judge (Print) Was a time extension granted? Yes No Was a resolution reached? Yes No Partial 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 Contact NAIC code or Insurer code Insurer/TPA claim # Pursuant to section 402.1 of the Act, the parties herewith request that the Department schedule an informal conference in the above case. The employee will be represented by an attorney at the informal conference: Yes No Employee counsel Employer counsel002 Adjudicating judge002 Suggested informal002 conference judge (if agreed upon) Last name Last name Last name Last name First name First name First name First name PA Attorney ID number PA Attorney ID number Pending petition(s): Notice: Date of this notice Attorney222s signature Attorney222s name (typed/printed) ZIP Employee/Dependent/Guardian/Personal Representative signature Telephone COUNSEL FOR PARTY SUBMITTING REQUEST: Attorney222s name PA Attorney ID number Firm name Address Address City/Town State Telephone -- MM DD YYYY American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS AND PROCEDURES002 the informal conference.003003003003relating to a petition(s).manager from the district where the claim is pending.003003003003002003002003003003003003003003003003003003the parties during the conference and may use other reasonable means to encourage an informal resolution.the petition(s) is (are) resolved.003003to writing which will be signed by the parties. The original informal conference agreement and attached documents shall003003003003adjudicating judge, but the Compromise and Release Agreements will not be accepted at informal conferences.77 P.S. 2471039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. 2474117 (relating to insurance fraud). toll-free inside PA: 800.482.2383 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 *753*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com