Fill and Sign the Claim Petition under Form

\ \ DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION DEFENDANT’S ANSWER TO CLAIM PETITION UNDER PA WORKERS’ COMPENSATION ACT EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - DATE OF INJURY WCAIS CLAIM NUMBER EMPLOYEE First name Last name Date of birth If deceased - Dependent/Guardian/Personal Representative First name Last name 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 narr ativ e Check if occupational disease - - MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN \ VS. INSURER, FUND 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 # “FUND” SHALL MEAN THE UNINSURED EMPLOYERS GUARANTY FUND, SUBSEQUENT INJURY FUND, SELF-INSURANCE GUARANTY FUND OR PRE-SELF-INSURANCE GUARANTY FUND. TO YOUR HONORABLE JUDGE: In answer to the captioned claim, the defendant respectfully pleads as follows: (Answer must be identi�ed by numerical order in direct response to corresponding numbered allegations asserted in the claim petition.) LIBC-374 REV 09-13 (Page 1) As a matter of further defense, the defendant states the following: PLEASE ENTER MY APPEARANCE FOR DEFENDANT : Attorney’s name PA Attorney ID number Firm name Address Address City/Town Sta te Date �led MM DD YYYY - - ZIP Telephone Attorney’s signature Attorney’ s name (typed/printed) Defendant’s signature Defendant’s name (typed/printed) N otice: This answer 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. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. You must send a copy to all unrepresented parties, and to the attorney of record for all other parties which are represented by counsel. 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 answer to all parties and their attorneys, if known. Answers must be �led within 20 days of the assignment of the petition. Every fact alleged in the petition not speci�cally denied by this answer shall be deemed to be admitted. Questions regarding the completion of this form may be directed to the 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 W orkers’ 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 Services 717.772.3702 Claims Information Services toll-free inside PA: 800.482.2383 local & outside P A: 717.772.4447 Hearing Impaired toll-free inside PA TTY : 800.362.4228 local & outside PA TTY: 717.772.4991 Email ra-li-bwc-helpline@pa.gov *374* Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program LIBC-374 REV 09-13 (Page 2)