The Pennsylvania Statement of Wages (For Injuries Occurring On And After June 24, 1996) is a document used in the state of Pennsylvania to report wages and other income earned by a worker who has been injured on the job. It is typically completed by the injured worker's employer and is used to determine the worker's compensation benefits. This document is also used to report income earned by a worker who has been injured off the job, provided the injury is related to the worker's employment. There are two types of this statement: the “Long Form” and the “Short Form.” The Long Form must be used when a worker has more than one employer, while the Short Form can be used when a worker has only one employer. The Long Form must also be used when the worker has any income from outside sources, such as investments or rental income, while the Short Form can be used when the worker has no other sources of income. Both forms must be signed and dated by the employer and must be submitted to the Pennsylvania Department of Labor and Industry in order to receive worker's compensation benefits.
Pennsylvania Statement of Wages (For Injuries Occurring On And After June 24 1996)
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FAQ
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).
In Pennsylvania, the 90-day rule states that injured workers must initially see "panel physicians??a list of pre-approved doctors posted by the employer?within 90 days of their workplace injury to receive compensation. If they see a different doctor, workers' compensation won't necessarily have to cover the cost.
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.
Worker's compensation form completed when the patient first seeks treatment for a work-related illness or injury. It does not contain a signature line. It is filed with State Worker's Compensatin Board/Commission.
Sole proprietors. Employees not working within the regular course of the employer's business. Agricultural workers hired to do less than 30 days of work and who earn less than $1,200/year from one employer. Employees who request an exemption based on religious beliefs or executive status in certain corporations.
In Pennsylvania, you have 120 days to inform your employer that you have been injured at work. This is the first step in receiving workers' compensation benefits.
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.
1994) (?Section 204(a) prohibits, as against public policy, an employer from agreeing with his employee to hold employer harmless for any future injury the employee may suffer.?) (emphasis changed).