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). LIBC-496 REV 03-11 (Page 1) 496 0311 American LegalNet, Inc. www.FormsWorkFlow.com 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 LIBC-496 REV 03-11 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com