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If the employee had more than one employer at the time of injury, a separate Statement of Wages form must be completed for each employer. Reenacted and Amended June 21, 1939, P.L.520, No.281.The Pennsylvania Workers' Compensation Act provides wage loss and medical benefits to compensate employees suffering from work-related injuries or diseases. Items 37 - 43 — considerations in regard to completing the cause-of-death statement. Items 37 - 43 — considerations in regard to completing the cause-of-death statement. Not be absent from the U.S. for a full calendar month or 30 or more consecutive days. 01990574 (June 22, 2004). CAUSATION - GILLETTE INJURY. Marking the 75th anniversary of the Universal Declaration of Human Rights. He performed surgery on February 23, 1996 and removed the offending spurs.