Get Pa Libc-344 2001-2025

Filling out the PA LIBC-344 form is an essential step in reporting an occupational injury or disease in Pennsylvania. This guide will provide you with clear instructions to ensure accurate completion of the form online, making the process smoother for users with various levels of experience.

Follow the steps to complete the PA LIBC-344 form online effectively.

1. Press the ‘Get Form’ button to access the PA LIBC-344 online, where you can begin filling out the form.
2. Enter the employee's Social Security Number in the designated field to identify the individual involved in the report.
3. Fill in the date of injury by selecting the appropriate month, day, and year from the dropdown options.
4. Provide the employee’s first and last name, then enter their street address, city, state, zip code, and county.
5. Input the employee’s phone number and select their gender (male or female), marital status (married or single), and number of dependents.
6. Insert the employee’s date of birth, occupation or job title, and NCCI class code, if known.
7. Indicate the employment status by selecting the appropriate code: FT for full-time, PT for part-time, SL for seasonal, VO for volunteer, or ZZ for other.
8. Provide the employer's name, street address, city, state, zip code, SIC code, employer FEIN, and phone number.
9. Note the county of the employer and enter the NAICS code, if applicable.
10. Indicate whether the employee received full pay for the day of the injury by selecting 'Yes' or 'No'.
11. Enter the time the employee began work, the last day worked, and the time of occurrence of the injury (AM or PM).
12. Fill in the date the disability began, the date the employer was notified, and the date returned to work.
13. Document the date of hire and the contact person's first and last name along with their phone number.
14. Provide details regarding the type of injury and parts of the body affected, including the cause of the injury.
15. Indicate whether the injury or illness occurred on the employer’s premises, and provide specifics if out of state.
16. Describe how the injury or illness occurred, including any objects or substances involved.
17. Provide details on initial treatment received by the employee and indicate if the injury was fatal.
18. Complete the witness information and details about the person submitting the form, including their contact information.
19. Review all entered information for accuracy before proceeding to save, download, print, or share the completed form.

Complete your PA LIBC-344 form online today to ensure timely reporting of occupational injuries.