Fill and Sign the 1237 Application of Offset for Social Security Old Age Benefits Form

LIBC-756 REV 04-18 (Page 1) EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER Name Address Address City/Town State ZIP County Telephone FEIN Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim # - - - - DATE OF INJURY WCAIS CLAIM NUMBER MM DD YYYY EMPLOYEE \ EMPLOYER \ \ INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) First name Last name Date of birth Address Address City/Town State ZIP County Telephone READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM. Section 204 of the Workers’ Compensation Act requires employees receiving wage-loss benefits to report the receipt of unemployment compensation, social security (old age) benefits, severance and pension benefits. COMPLETE AND RETURN THIS FORM TO THE INSURER OR SELF-INSURED EMPLOYER IDENTIFIED ON THIS FORM. EMPLOYEE’S REPORT OF BENEFITS FOR OFFSETS (UNEMPLOYMENT COMPENSATION, SOCIAL SECURITY [OLD AGE], SEVERANCE AND PENSION BENEFITS) TYPE OF BENEFIT AMOUNT RECEIVED FREQUENCY RECEIPT BEGAN DATE(MM/DD/YYYY) RECEIPT ENDED DATE(MM/DD/YYYY) Unemployment Compensation Gross $ . Weekly Biweekly / / / / Net $ . Other Social Security(old age) Gross $ . Weekly Biweekly / / / / Net $ . Other Severance Gross $ . Weekly Biweekly / / / / Net $ . Other Pension Gross $ . Weekly Biweekly / / / / Net $ . Other Complete the following information, indicating the type, amount and frequency (i.e.: weekly, biweekly, or other [specify]) of the benefits being received. Include the date such receipt began and ended (if applicable). If you are not receiving a particular type of benefit, indicate by writing “not applicable” or “none” in the appropriate space. If you are receiving pension benefits from the employer directly liable for your workers’ compensation, indicate the percent of the pension which is funded by the employer or check the box for ‘percentage unknown’. % \ Percentage unknown (OVER) DEPARTMENT OF LABOR & INDUSTRYBUREAU OF WORKERS’ COMPENSATION LIBC-756 REV 04-18 (Page 2) Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud). Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 PA Relay 7-1-1 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 *756* Did you “roll over” pension benefits into an IRA Account? Yes No Amount “rolled over” $ . (IRA benefits are not offset until you begin withdrawing them from your account.) I verify that this information is true and correct, based upon my knowledge, information and belief. I understand false statements are subject to the penalties of 18 Pa. C.S. §4909, relating to unsworn falsification to authorities. Employee signature If you are receiving any wages from employment or self-employment, check this box . You must report this to your insurer or self-insured employer. Contact your insurer/employer for that reporting form (LIBC-760). - - DATE MM DD YYYY INSTRUCTIONS TO EMPLOYEES: If you are receiving workers’ compensation wage-loss benefits due to an injury which occurred on or after June 24, 1996 , you must report the receipt of the following: • Unemployment compensation benefits • Social Security (old age) benefits • Severance benefits paid by the employer directly liable for your workers’ compensation • Pension benefits to the extent funded by the employer directly liable for your workers’ compensation Your workers’ compensation benefits may be adjusted if you are receiving any of the above benefits. You are required to acknowledge both the receipt of and changes to any of the benefits listed above through the immediate completion and submission of this form. FAILURE TO REPORT THE RECEIPT OF OR CHANGES TO ANY OF THE BENEFITS LISTE\ D ABOVE MAY SUBJECT YOU TO PROSECUTION UNDER ARTICLE XI OF THE WORKERS’ COMPENSATION ACT RELATIN\ G TO INSURANCE FRAUD.