DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OF ADJUDICATION PETITION TO/FOR:002 (Check any that apply)002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - (Reduce/increase amount of workers222 compensation) Penalties (For violation of the act, rules and regulations)002003002003002003Review medical treatment and/or billing DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY Seek approval of a compromise and release agreement (Ask judge to approve settlement) (Ask judge to set aside agreement to stop compensation) 002003a special supersedeas hearing to be scheduled (Employee fully recovered without any disability) Employee Employer/Insurer EMPLOYEE First name Last name Date of birth If deceased - Dependent/Guardian/Personal Representative First name Last name Address Address City/Town State ZIP County Telephone 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 EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN VS. INSURER, FUND or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim # 223FUND224 SHALL MEAN THE UNINSURED EMPLOYERSGUARANTY FUND, SUBSEQUENT INJURY FUND,SELF-INSURANCE GUARANTY FUND ORPRE-SELF-INSURANCE GUARANTY FUND. TO YOUR HONORABLE JUDGE: The above petitioner requests the workers222 compensation judge to order the above action as of for the following reason(s). MM DD YYYY 1.Full recovery 10.Medical bills unpaid11.Medical bills not related3.Work generally available12.Worsening of condition4.Able to return to unrestricted work13.Injury causing decreased earning power5.Has returned to work14.Section 314 order violated6.Reasonable treatment refused15.Voluntary withdrawal from workforce16.Violation of the act, rules and regulations8.Incorrect description of injury17.Subrogation, credit or offset for9.Incorrect average weekly wage UC Social Security Third party recovery S&A Pension -- American LegalNet, Inc. www.FormsWorkFlow.com 18.Otherbeing paid have been paid based on a: Notice of compensation payable dated Agreement dated Supplemental agreement dated MM MM MM ---DD DD DD ---YYYY YYYY YYYY Judge222s order dated Board order dated Court order dated MM MM MM ---DD DD DD ---YYYY YYYY YYYY Is supersedeas being requested pursuant to Section 413(A.2)?If yes, list reasons: Yes No Average weekly wage $ Applicable weekly total disability rate $ Date of most recent payment --Amount $ . . . MM DD YYYY PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney222s name PA attorney ID number Firm name Address Address City/Town State ZIP Telephone Petitioner or Representative222s signature Petitioner or Representative222s name (typed/printed) COUNSEL FOR RESPONDENT (if known): Attorney222s name PA attorney ID number Firm name Address Address City/Town State ZIP Telephone Date of petition - - MM DD YYYY N1010 N. Seventh St, Suite 20, Harrisburg, PA, 17102-1400. You must send a copy to all other parties, and to the attorneys of all other parties, if the attorneys are known. A proof-of-service must be attached. A proof-of-service is a signed is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and 2471039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. 2474117 (relating to insurance fraud). Employer Information Claims Information Services Email Services toll-free inside PA: 800.482.2383 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 Hearing Impaired *378*Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com