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Statement Of Account Of Compensation Paid Form. This is a Pennsylvania form and can be use in Workers Comp.
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Tags: Statement Of Account Of Compensation Paid, LIBC-392, Pennsylvania Workers Comp,
EMPLOYEE SOCIAL SECURITY NUMBER
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
STATEMENT OF ACCOUNT OF
COMPENSATION PAID
(For all Workers' Compensation and
Occupational Disease cases
including fatalities)
-
DATE OF INJURY
-
-
MONTH
DAY
PA BWC CLAIM NUMBER (IF KNOWN)
EMPLOYEE
EMPLOYER
First Name
Name
Last Name
YEAR
Address
Address
Address
Address
City/Town
City/Town
State
Zip
Zip
County
County
Telephone (
Telephone (
State
)
)
FEIN
INSURER or THIRD PARTY ADMINISTRATOR (if self insured)
Name
NOTICE: This Statement of Account must be filed annually on all open cases
(check box below). This statement must also be filed at the termination
of a specific period of compensation payable (i.e. specific loss, death etc.) OR
when compensation is terminated or suspended by decision of Workers'
Compensation Judge, Workers' Compensation Appeal Board, or an appeal court.
Where applicable, certified copy of marriage or death certificate should
accompany this form.
Address
Address
City/Town
Telephone (
State
)
Bureau Code
County
FEIN
Claim #
(Select only one)
Zip
Final Statement of Account
Annual Statement of Account
This is to certify that the above named employer or insurer has paid compensation under the Pennsylvania Workers'
Compensation Act in the above case for
MONTH
DAY
-
MONTH
YEAR
-
weeks
to
YEAR
DAY
-
days covering the period from
-
at $
weekly.
392 1197- 1
LIBC-392 REV 11-97
(over)
For intermittent periods for disability:
Rate
From Date
To Date
# weeks
-
-
-
-
-
-
-
-
-
-
-
Total
-
Total Amount Paid in This Period
$
Total Amount of All Previous Payments
$
TOTAL COMPENSATION PAID
$
Total Medical
$
Burial Expense
$
Penalty Payments
$
TOTAL
$
DATE
Name of Employer/Insurer Representative
-
MONTH
DAY
Signature of Employer/Insurer 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
and may also be subject to criminal and civil penalties through Pennsylvania Act 165.
LIBC-392 REV 11-97
392 1197- 2
YEAR
