Fill and Sign the Bureau of Workers Compensation Forms

petition for physical examination or expert DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION interview of employee (section 314) EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - employee First name Last name Date of birth Address Address City/Town State ZIP County Telephone inJUry information Provide the following information if Employer has accepted liability for this injury: Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease DATE OF INJURY   WCAIS CLAIM NUMBER - - MM DD YYYY employer Name Address Address City/Town State ZIP County Telephone FEIN vs. insUrer or thirD party aDministrator (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim # NOTICE TO EMPLOYEE: Employer must indicate whether “physical examination” or “expert interview” is required by checking the appropriate boxes. Employee’s answer must be �led with the Workers’ Compensation Judge within twenty (20) days . 1. The insurer/employer alleges that it requested the employee to submit to a physical examination expert interview by , HEALTH CARE PROVIDER’S/EXPERTS NAME AND ADDRESS AND FIELD OF SPECIALTY OR EXPERTISE for the purposes of on , and the employee refused or failed IME/IRE/EXPERT INTERVIEW MM DD YYYY to appear at such examaination or interview. 2. The date of last physical examination of the employee by the health care provider chosen by the insurer/employer or - - expert interview of the employee by the expert chosen by the insurer/employer was on . DD YYYY 3. If the petition is for the purpose of an IRE, the date of the request was on . MM DD YYYY 4.  Wherefore the insurer/employer petitions the workers’ compensation Judge to order the employee to submit to  a physical examination   an expert interview by or by such health care HEALTH CARE PROVIDER’S/EXPERTS NAME provider(s)/expert(s) as may be designated by the Workers’ Compensation Judge at such time and place as may be set and determined . IME/IRE/EXPERT INTERVIEW - - MM - - Identify documents previously �led with the Bureau of Workers’ Compensation: Notice of Compensation Payable dated Supplemental Agreement dated Other dated Petition dated MM DD YYYY - - MM DD YYYY - - MM DD YYYY - - MM DD YYYY - - 5. This is an Act 46 (�re�ghter cancer) claim LIBC-499 REV 09-13 (Page 1)                       claimant MUST BE serveD please enter my appearance for petitioner coUnsel for responDent (if known) Attorney’s name Attorney’s name PA Attorney ID number PA Attorney ID number Firm name Address Address City/Town State ZIP Firm name Address Address City/Town State ZIP Telephone Telephone Petitioner or representative’s signature - - Date of petition MM DD YYYY Petitioner or representative’s name (typed/printed) NOTE: This petition must be �lled out as fully as possible. If not �ling electronically, the original must be sent   to the Workers’ Compensation Of�ce of Adjudication, 1010 N 7th Street, Suite 202, Harrisburg, PA, 17102-1400.   You must send a copy to all other parties, and to the attorneys of all other parties, if the attorneys are known.   A proof of service must be attached. A proof of service is a signed statement signed by you verifying that you   have sent a copy of the petition to all parties and their attorneys, if known. Questions regarding the completion   of this form may be directed to Bureau of Workers’ Compensation Claims Information Services.    Any individual �ling 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 toll-free inside PA TTY: 800.362.4228 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991 *499*   Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-499 REV 09-13 (Page 2)