DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION PETITION FOR002 COMMUTATION002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP CountyTelephone INJURY INFORMATION Provide the following information if Employer has accepted liability for this injury: Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease DATE OF INJURYWCAIS CLAIM NUMBER - - MM DD YYYY . compensation payable in the captioned case, as provided under Section 316 of the Pennsylvania Workers222 Compensation Act, and to order payment of said compensation in one lump sum to at its then value discounted American LegalNet, Inc. www.FormsWorkFlow.com PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney222s name PA Attorney ID number Firm name Address Address City/Town State ZIP Telephone Date of petition -- Petitioner or Representative222s signature MM DD YYYY Petitioner or Representative222s name Employer Information Claims Information Services Email Services Hearing Impaired *34*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com