Fill and Sign the Employee Report of Wages and Physical Condition Pa Dli Form

\ \ \ employee report of wages department of labor & industry bureau of workers’ compensation and physical condition EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - employee First name Last name Date of birth Address Address City/Town State ZIP County Telephone failUre to complete this form may sUBJect yoU to article Xi of the wc act relating to fraUd. yoU mUst complete and retUrn this form within 30 days of Beginning employment or self-employment DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY employer Name Address Address City/Town State ZIP County Telephone FEIN 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 # 1. Are you now employed? Yes No 2. Are you now self-employed? Yes No 3. Have you been employed or self-employed at any time while receiving workers’ compensation bene�ts? Yes No If you answered yes to one of the questions, please complete the following: Occupation(s): 4. Has your physical condition (caused b y your work injury) changed? Yes No If yes, attach medical report. 5. Is there any other information you are aware of that is relevant in determining your entitlement to, or amount of compensation? Y es No If yes, please explain: (OVER) LIBC-750 REV 09-13 (Page 1) 6. Names of employers for whom you have worked since your date of injury: Name Name Address Address Address Address City/Town State ZIP City/Town State ZIP Period of employment: Period of employment: - - From - - From MM DD YYYY MM DD YYYY - - To - - To MM DD YYYY MM DD YYYY Amount of wages $ . Amount of wages $ . if self-employed Name Address From - - Address MM DD YYYY City/Town State ZIP Period of employment: To - - MM DD YYYY From - - MM DD YYYY Amount of wages $ . To - - MM DD YYYY Amount of wages $ . 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. §4904 relating to unsworn falsi�cation to authorities. employee First name DATE OF NOTICE Last name MM DD YYYY Signature Section 311.1(A) of the Workers’ Compensation Act requires employees who are receiving workers’ compensation, or who have �lled a petition to receive workers’ compensation, to report earnings from employment or self-employment. You must complete and return this form to the sender within thirty (30) days of beginning such employment or self-employment. employee is to retUrn this completed form to the insUrer or third party administrator shown on the front. 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 - - *750* Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program LIBC-750 REV 09-13 (Page 2)