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  • Libc 500 Rev 5 09 Form

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772. 0621 www. dli. state. pa.us LIBC-500 REV 5-09 221-8805 1/12 Auxiliary aids and services are available upon request to individuals with disabilities. CLEAR PRINT REMEMBER It is Important to Tell Your Employer about Your Injury The name address and telephone number of your employer s workers compensation insurance company third-party administrator TPA or person handling workers compensation claims for your company are shown below. Employer Name Date Posted IF INSURED Complete all applicable spaces IF SOMEONE OTHER THAN INSURER IS HANDLING CLAIMS Name of Insurance Company Name of TPA Claims administrator Address Telephone Number Insurer s Bureau Code IF SELF-INSURED Name of person handling claims at the self-insured Self-Insured Bureau Code Department of Labor Industry Bureau of Workers Compensation 1171 S* Cameron Street Room 103 Harrisburg PA 17104-2501 717. CLEAR PRINT REMEMBER It is Important to Tell Your Employer about Your Injury The name address and telephone number of your em....

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Pennsylvania short term disability benefits may be awarded to incapacitated or sick employees who cannot work, yet expect their ailments to last less than one year. Short-term disability insurance can also be purchased through an insurance company if an employer does not cover short term disability benefits.

Specific loss payments in Pennsylvania are paid out to the injured worker under the condition that you lost a body part or lost the ability to use the body part in question. The amount is based upon the body part that was lost or damaged and how much time you will miss from work due to the injury.

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.

Total Disability (TT or PT) Payments are made while the worker is temporarily unable to perform any work and are based on 2/3 of the injured individual's average weekly wage. They are paid for the duration of disability. Although it is theoretically possible to receive wage-loss benefits for life, this is not common.

Those who qualify for temporary total disability may receive two-thirds of their average weekly wage up to a cap set and adjusted annually by the Pennsylvania Department of Labor and Industry. Workers in lower wage brackets may be entitled to up to 90 percent of their average weekly wage.

Temporary Total Disability (TTD) Benefits: There is a 3-day waiting period for the payment of disability benefits. If the disability exceeds 14 days, the 3-day waiting period is waived. An Injured worker is paid 66 2/3 percent of their average weekly wage when it falls between $605.26 and $1,210.50 wage paid is 60%.

Are age 18 or older. Are not currently receiving benefits on your own Social Security record. Are unable to work because of a medical condition that is expected to last at least 12 months or result in death; and. Have not been denied for disability in the last 60 days.

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.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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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