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 15 State Forms found

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CLAIM PETITION FOR WORKERS' COMPENSATION

 LIBC-362 REV 08-20

AUTHORIZATION FOR ALTERNATIVE DELIVERY OF COMPENSATION PAYMENTS

LIBC-10 REV 09-22

INFORMAL CONFERENCE AGREEMENT FORM

 LIBC-754 REV 04-18

REMEMBER: IT IS IMPORTANT TO TELL YOUR EMPLOYER ABOUT YOUR INJURY

 LIBC-500 REV 09-22

NOTICE OF CLAIM AGAINST UNINSURED EMPLOYER

 LIBC-551 REV 09-20

NOTICE OF WORKERS’ COMPENSATION DENIAL - EDI SUBMISSION ONLY

 LIBC-496 REV 04-18

SECTION 304.2 APPLICATION FOR RELIGIOUS EXCEPTION OF SPECIFIED EMPLOYEES FROM THE PROVISIONS OF THE PENNSYLVANIA WORKERS’ COMPENSATION ACT

 LIBC-14A REV 01-24

SUPPLEMENTAL INFORMATION ADDENDUM TO APPLICATION FOR MEMBERSHIP IN A GROUP WORKERS’ COMPENSATION FUND - ONLINE ONLY

 LIBC-368 REV 03-24

SUPPLEMENTAL INFORMATION ADDENDUM TO APPLICATION AS A GROUP WORKERS’ COMPENSATION FUND - ONLINE ONLY

 LIBC-369 REV 04-18

CHILD SUPPORT LIEN AFFIDAVIT

 LIBC-504 01-15

ANNUAL REPORT OF ACCIDENT & ILLNESS PREVENTION PROGRAM STATUS BY INDIVIDUAL SELF-INSURED EMPLOYERS

 LIBC-220E REV 10-22

EMPLOYERS PANEL PROVIDER REQUIREMENTS

 LIBC-20 REV 09-22

QUALIFICATIONS OF REVIEWER

 LIBC-131 REV 09-22

Statement of Complaint

REMEMBER: IT IS IMPORTANT TO TELL YOUR EMPLOYER ABOUT YOUR INJURY (Spanish)

 LIBC-500(ESP) REV 09-22
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