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 Social Security Number: ________ - _______ - _________ PETITION FOR PENALTIES Date of Injury: ______/______/____________ MM DD YYYY PA BWC Claim Number: ____________________________ (IF KNOWN) Employee Employer First Name Last Name Name __________________________________ ________________________________________________ _______________________________________________________________________________________ Street 1 Street 1 ________________________________________________________________________________________ _______________________________________________________________________________________ Street 2 Street 2 _______________________________________________________________________________________ _______________________________________________________________________________________ City/Town City/Town State Zip Code State Zip Code __________________________________________________ _________ ____________ - __________ ________________________________________________ ___________ _____________ - __________ County Telephone County __________________________________________ (_______) _______ - __________________ ____________________________________________ Telephone VS. FEIN (_______)_______-____________________________ _______________________ Insurer or Third Party Administrator (if self-insured) Injury Name Description of Injury and Cause of Death ___________________________________________________________________________________________ ________________________________________________________________________________________ Street 1 ________________________________________________________________________________________ ________________________________________________________________ _________________ _______________________________________________________________ __________________ Street 2 ________________________________________________________________________________________ __________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ City/Town State Zip Code __________________________________________________ _________ _____________ - __________ ________________________________________________________________________________________ ________________________________________________________________________________________ _________________________________________________________________________________________ ____________________________________________ Check if Occupational Disease L PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney Name Telephone Bureau Code (_______) _______-___________________________ ______________________ County ____________________________________________ Claim Number FEIN ____________________________________________ _____________________ Counsel for Respondent (if known) Name ________________________________________________________________________________________ Firm Name Firm Name ________________________________________________________________________________________ Street 1 Street 2 State Zip Code _____________________________________________________ _________ __________ - _________ Telephone _______________________________________________________________________________________ Street 2 ________________________________________________________________________________________ (_______) _______-___________________________ _______________________________________________________________________________________ Street 1 ________________________________________________________________________________________ City/Town _______________________________________________________________________________________ _______________________________________________________________________________________ City/Town State Zip Code _____________________________________________________ ___________ __________ - _______ PA Attorney ID Number Telephone PA Attorney ID Number _________________________________ (_______) _______-___________________________ _________________________________ NOTICE: This petition should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left corner. LIBC-686 REV 6-04 (Page 1) (OVER) American LegalNet, Inc. www.USCourtForms.com 1. The aforementioned Employee, or his/her Representative, ____________________________________________________, believes that the aforementioned Insurer, TPA, or Self-insured Employer has violated the terms of the Workers’ Compensation Act and/or Regulations in the processing or payment of compensation to the Employee(s) in that: (Specify, in detail, the nature of the alleged violation(s) and the Section of the Law/Regulation which applies. Attach an additional sheet, if necessary.) 2. Further, the Employee requests that the Insurer, TPA, or Self-insured Employer be required to pay penalties in the total amount of $__________.____, which represents ________ percentage of the compensation to which the Employee was entitled, but L not paid which was L paid late for the period from L illegally suspended _______/_______/___________ MM DD YYYY to _______/_______/________ MM DD YYYY WHEREFORE, the Employee requests that the Department of Labor and Industry require the Insurer, TPA, or Self-insured Employer to answer this Petition within twenty(20) days of service of this Petition on the adverse parties as provided for by Section 416 of the Workers’ Compensation Act, and to schedule such hearings as are necessary to determine and grant the relief requested in the previously mentioned paragraphs. DATE OF THIS NOTICE: ______/______/___________ MM DD YYYY Petitioner First Name Last Name _________________________________ _____________________________________________ Signature ___________________________________________________________________________________ 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. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-686 REV 6-04 (Page 2) American LegalNet, Inc. www.USCourtForms.com