Get Application For Supersedeas Fund Reimbursement ...

Filling out the Application for Supersedeas Fund Reimbursement is a straightforward process that ensures insurers can request reimbursement for compensation paid to claimants. This guide provides clear, step-by-step instructions to assist you in completing this form accurately.

Follow the steps to successfully complete your application.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering the date of injury and the PA BWC claim number if known. These fields are crucial for accurately identifying the case.
3. Provide your employer's name, followed by the employee's first and last name. Ensure that spelling is correct to avoid complications.
4. Fill in the employer's and employee's address, including street address, city/town, state, zip code, and county. This ensures proper communication regarding the application.
5. Input the telephone numbers for both the employer and the insurer or third-party administrator, ensuring they are reachable for any follow-up.
6. Under the section regarding reimbursement details, include the specific dates compensation was paid, how much compensation was paid weekly, and the total amount. Make sure to be precise to avoid future discrepancies.
7. Attach proof of payment documentation, which can be in the form of affidavits or canceled checks. This is necessary to validate your claims in this application.
8. In the verification section, provide the name and title of the submitter, and ensure that the signature is included to finalize the application.
9. Review the completed form for any incomplete sections or errors before submission. Mistakes can lead to delays or rejection of the application.
10. Once the form is completed, save changes, download it for your records, print a copy if needed, or share it as required.

Begin filling out your Application for Supersedeas Fund Reimbursement online today to ensure a smooth processing experience.