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Name of Employer Name of Insurer Claim Number (if known) Date of Birth Employee SS# Date of Injury Date of Report Provider Name.

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The Employer's Report of Occupational Injury or Illness (Form 5020). Every employer is required to file a complete report of every occupational injury or illness to each employee which results in lost time beyond the date of injury or illness or which requires medical treatment beyond first aid*.

Section 311 of the Pennsylvania Workers' Compensation Act provides that notice of a work injury must be given to an employer within 120 days or it is barred.

Workers' Compensation is tax-free. In Pennsylvania, the weekly compensation rate amounts to 66% of the injured worker's average weekly wage if they earned between $810.76 and $1,621.50 prior to the injury. For workers who earn between $600.56 and $810.75, the weekly compensation rate is $540.50.

Under the PA Bureau of Workers' Compensation, your employees can receive a weekly wage to cover their medical treatment and lost wages after suffering a work-related injury or disease. Workers' comp allows you to provide benefits to your employees while also protecting yourself from lawsuits.

Form LIBC-344 First Report of Injury (FROI). As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed within 10 days from notice of a work-related injury. Fatalities must be reported within 24 hours.

An employee injury is to be reported to the employer within 21 days; if not reported within 120 days from the date of injury or having knowledge of a work-related disease, no compensation is allowed (except for cases involving progressive diseases).

When an employee has been injured or has a recurrence of a previously reported injury, immediately contact SWIF using our Toll Free Hotline at 1-888-388-7943(SWIF).

How to File a Workers' Compensation Claim in PA Inform Your Employer of Your Injury. ... Seek Immediate Medical Attention. ... File Your Claim With the Pennsylvania Department of Labor and Industry. ... Fill Out All the Required Workers' Compensation Claim Forms.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232