Fill and Sign the Compensation Denial Form

NOTICE OF WORKERS’ COMPENSATION DENIAL SOCIAL SECURITY NUMBER WC ID NUMBER - - WCAIS CLAIM NUMBER - -DATE OF INJURY MM DD YYYY - - - - DATE OF NOTICE Date of birth County Telephone MM DD YYYY MM DD YYYY Name Address Address City/Town State ZIP County Telephone FEIN Name Address Address City/Town State ZIP County Telephone FEIN Insurer/Administrator claim # Name Address Address City/Town State ZIP County Telephone FEIN NAIC code Insurer code Insurer/Administrator claim # Part of body injured Nature of injury Accident/injury description narrative County Check if occupational disease NOTICE TO EMPLOYEE: The employer/insurer has decided to deny you workers’ compensation bene�ts. You have the right to contest this denial by timely �ling a petition. Petitions may be either electronically �led in WCAIS or sent to the Workers’ Compensation Of�ce of Adjudication, 1010 N. Seventh St., Suite 202, Harrisburg, PA 17102-1400. Do not use this form to accept a medical-only claim. This notice shall be sent to the employee or dependent and �led with the Bureau of Workers’ Compensation via electronic format no later than 21 days after notice or knowledge to the employer of the employee’s disability or death. A separate paper copy of this EDI-generated form should not be uploaded or sent to the Bureau. EMPLOYEE EMPLOYER INSURER TPA LIBC-496 REV 03-16 (Page 1) (OVER) Speci�c information regarding this claim is on the reverse side of this form. ALLEGED INJURY INFORMATION DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION SAMPLE-NOT FOR USE Claims representative’s name Telephone LIBC-496 REV 03-16 (Page 2)Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program 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 Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991 - - MM DD YYYY To view your claim �le, log on to www.wcais.pa.gov EMPLOYEES’ RIGHTS TO CONTEST DENIAL You have the right to contest this denial of your claim for workers’ compensation bene�ts. Your petition will be heard by a workers’ compensation judge. You and your employer will have the opportunity to testify and provide medical evidence with respect to your claim. Both you and your employer will have the right to bring witnesses. You may retain an attorney to represent you in this proceeding although representation by an attorney is not required by law. Because of the legal complications that can arise in occupational disease and workers’ compensation cases, you may want to consider legal advice. If you do not know how to contact an attorney, please contact your local Bar Association or the Pennsylvania Bar Association at 800-692-7375 for guidance in obtaining an attorney. The procedure for �ling a petition is as follows: 1. To �le a petition you may access WCAIS from www.wcais.pa.gov, or upon request a petition, Form LIBC-362, will be mailed to you. You or your attorney may �le your petition online or complete and return the original petition to the Workers’ Compensation Of�ce of Adjudication by electronically attaching the document to a claim in WCAIS or by mail to the the Workers’ Compensation Of�ce of Adjudication, 1010 N. Seventh St., Suite 202, Harrisburg, PA 17102-1400. 2. A petition for an injury must be �led within three years of the date of injury. Filings for occupational disease claims, disability, or death must occur within 300 weeks from last exposure. A petition must be �led no later than three years from that date. Failure to �le a petition within these rules may result in a loss of your claim. 3. You must give notice of your work-related injury or disease to your employer within 120 days of the date you knew (or should have known) that you were injured or had contracted a work-related disease. 4. When your petition is �led with the Workers’ Compensation Of�ce of Adjudication, it will be assigned to a judge for a hearing. You will be noti�ed of your hearing date. All parties are requested to be fully prepared prior to the �rst hearing. If you need petition forms or have questions, please go to www.wcais.pa.gov or contact one of the Information Services numbers listed below. Date the employer received notice or knew of alleged injury or date of employee’s claimed disability:This date must be completed. The employer/insurer declines to pay workers’ compensation bene�ts to claimant because: 1. The employee did not suffer a work-related injury. The de�nition of injury also includes aggravation of a pre-existing condition or disease contracted as a result of employment. 2. The injury was not within the scope of employment. 3. The employee was not employed by the defendant. 4. The employee did not give notice of his/her injury or disease to the employer within 120 days within the meaning of Sections 311-313 of the Workers’ Compensation Act. 5. Other good cause; please explain fully in the space below. SAMPLE-NOT FOR USE