COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 TTY 800-362-4228 Date of Injury: MM DD PA BWC Claim Number: YYYY (IF KNOWN) Employer Employee Last Name First Name Social Security Number: NOTICE OF WORKERS' COMPENSATION BENEFIT OFFSET Name Street 1 Street 1 Street 2 Street 2 State City/Town Zip Code City/Town County Telephone County State Zip Code FEIN Telephone Insurer or Third Party Administrator (if self-insured) Name Street 1 Street 2 City/Town Zip Code State Telephone DATE OF THIS NOTICE: Bureau Code County MM DD YYYY Claim Number FEIN Attorney for Insurer/Employer (if known) Attorney for Employee (if known) Name Name Firm Name Firm Name Street 1 Street 1 Street 2 Street 2 State City/Town Zip Code City/Town PA Attorney ID Number Telephone State Zip Code PA Attorney ID Number Telephone Claim Representative First Name Last Name Signature Telephone A COPY OF THIS FORM AND ATTACHMENTS ARE TO BE PROVIDED TO THE EMPLOYEE, THE EMPLOYEE'S ATTORNEY (IF KNOWN), AND THE ORIGINAL MUST BE MAILED TO PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY, BUREAU OF WORKERS' COMPENSATION, AT THE ADDRESS SHOWN ABOVE. (OVER) Ll BC-761 REV 8-01 American LegalNet, Inc. www.USCourtForms.com LIBC-761 You are hereby notified that the workers' compensation insurance carrier/employer (specified previously) is taking a credit that will offset your workers' compensation wage-loss benefits as authorized by Section 204 of the Pennsylvania Workers' Compensation Act. If you pay federal, state, or local taxes on an offset amount, provide a written statement to your employer/insurer showing the amount of the taxes you paid on the offset to receive reimbursement for these taxes. You may file for this reimbursement after the end of the calendar tax year. Your offset is for the following: Old Age Social Security benefits which you began to receive following an injury which occurred on or after June 24, 1996. (This offset is for one-half or 50% of this Social Security benefit.) Unemployment compensation benefits. If you are eventually found to be ineligible for the unemployment compensation payment, you must notify the above insurer/employer which shall reinstate the offset workers' compensation benefits. . Pension benefits to the extent funded by the employer directly liable for the payment of your workers' compensation benefits due to an injury occurring on or after June 24, 1996. This employer can also take credit for investment income which is attributable to this contribution. Severance benefits paid by the employer directly liable for compensation and received subsequent to a workrelated injury occurring on or after June 24, 1996. Your current workers' compensation wage-loss benefit is $ paid: Weekly Bi-Weekly The offset credit of $ . your receiving $ An ending date of Other (specify): will be deducted from this amount beginning on: workers' compensation benefit payments. . MM . DD YYYY MM DD YYYY resulting in has been established for this offset or a portion of it to recoup prior offsetable benefits you received. After that date you will continue to receive reduced workers' compensation benefits in the amount of $ . per payment based on your continuing receipt of offsettable benefits. An ending date cannot yet be established for this offset due to the continuing nature of your benefits which are applicable to an offset. You will receive an additional notice if a change occurs in this offset. This form is to provide you with at least twenty (20) calendar day's notice of this offset prior to a change in your workers' compensation benefits. The offset was calculated as follows and additional calculations may be attached: Attached are the following documents supporting the basis for this offset: You may challenge this offset by filing a Petition to Review Compensation Benefit Offset with the Pennsylvania Department of Labor and Industry, Bureau of Workers' Compensation. Petitions can be obtained by calling the Bureau at 1-800-482-2383. Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. American LegalNet, Inc. www.USCourtForms.com