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Notice Of Workers Compensation Denial Form. This is a Pennsylvania form and can be use in Workers Comp.
Tags: Notice Of Workers Compensation Denial, LIBC-496, Pennsylvania Workers Comp,
EMPLOYEE SOCIAL SECURITY NUMBER
NOTICE OF WORKERS’
COMPENSATION DENIAL
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
DATE OF INJURY
DATE OF NOTICE
MONTH
DAY
YEAR
PA BWC CLAIM NUMBER (IF KNOWN)
MONTH
DAY
YEAR
EMPLOYEE
EMPLOYER
First Name
Name
Last Name
Address
Address
Address
Address
City/Town
City/Town
State
Zip
Zip
County
County
Telephone (
State
Telephone (
)
)
FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self insured)
ALLEGED INJURY INFORMATION
Name
Body Part(s) affected
Address
Type of Injury
Address
Description of Injury
City/Town
Telephone (
State
)
Zip
Bureau Code
County
Check if Occupational Disease
Claim #
FEIN
NOTICE: The employer/insurer has decided to deny you workers’ compensation benefits. You have the right to contest this
denial by timely filing a petition with the bureau.
Do not use this form to accept a medical-only claim. This denial shall be sent to the employee or dependent and filed with the bureau no
later than 21 days after notice or knowledge to the employer of the employee’s disability or death.
Date employer received notice or knew of alleged injury or date of employee’s claimed disability:
This date must be completed.
MONTH
DAY
YEAR
The employer/insurer declines to pay workers’ compensation benefits to claimant because:
1.
2.
3.
4.
5.
The employee did not suffer a work-related injury. The definition of injury also includes aggravation of a pre-existing
condition, or disease contracted as a result of employment.
The injury was not within the scope of employment.
The employee was not employed by the defendant.
The employee has not suffered a loss of wages as a result of an already accepted injury.
The employee did not give notice of his/her injury or disease to the employer within 120 days within the meaning of
Sections 311-313 of the Workers’ Compensation Act.
6. Other good cause. Please explain fully in the space below.
See Reverse Side For Employees’ Rights To Contest Denial
Name of Claims Representative
(
Signature of Claims Representative
)
Phone Number
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,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A.
§4117 (relating to insurance fraud).
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EMPLOYEES’ RIGHTS TO CONTEST DENIAL
You have the right to contest this denial of your claim for workers’ compensation benefits. Your petition will be
heard by a workers’ compensation judge. You and your employer will have the opportunity to testify and
provide medical evidence with respect to your claim. Both you and your employer will have the right to bring
witnesses. You may retain an attorney to represent you in this proceeding although representation by an
attorney is not required by law. Because of the legal complications that can arise in occupational disease and
workers’ compensation cases, you may want to consider legal advice. If you do not know how to contact
an attorney, please contact your local Bar Association or the Pennsylvania Bar Association at
800-692-7375 for guidance in obtaining an attorney.
The procedure for filing a petition is as follows:
1. At your request, a petition, Form LIBC-362, will be mailed to you. You or your attorney must complete and
return the original petition to the bureau. You must also send a copy to your employer. If you or your
attorney wish to file a petition electronically, you will find instructions for doing so on the bureau’s website,
www.dli.state.pa.us, under the Online Services link.
2. A petition for an injury must be filed within three years of the date of injury. For occupational disease claims,
disability or death must occur within 300 weeks from last exposure. A petition must be filed no later than
three years from that date. Failure to file a petition within these rules may result in a loss of your claim.
3. You must give notice of your work-related injury or disease to your employer within 120 days of the date you
knew (or should have known) that you were injured or had contracted a work-related disease.
4. When your petition is received by the Bureau of Workers’ Compensation, it will be assigned to a judge for
hearing. You will be notified of your hearing date. All parties are requested to be fully prepared prior to the
first hearing.
If you need petition forms or have questions, please contact the Bureau of Workers’ Compensation:
Employer Information Claims Information Services
Only People with Hearing Loss
E-mail
Services
toll-free inside PA: 800-482-2383 toll-free inside PA TTY: 800-362-4228 ra-li-bwc-helpline@
(717) 772-3702
local & outside PA: (717) 772-4447 local & outside PA TTY: (717) 772-4991
state.pa.us
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
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