Fill and Sign the Fillable Online Dickinsonstate Salary Reduction Agreement Form

DEPARTMENT OF LABOR & INDUSTRYBUREAU OF WORKERS’ COMPENSATION SUPPLEMENTAL AGREEMENT FOR COMPENSATION FOR DEATH DECEASED’S SOCIAL SECURITY NUMBER OR WC ID NUMBER - - - - DATE OF INJURY MM DD YYYY WCAIS CLAIM NUMBER DECEASED EMPLOYEE \ EMPLOYER First name Last name Date of birth Date of death \ DEPENDENT/GUARDIAN/PERSONAL REPRESENTATIVE \ INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) - - -- MM DD YYYY -- MM DD YYYY First name Last name Address Address City/Town State ZIP County Telephone INJURY INFORMATION \ \ Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease Name Address Address City/Town State ZIP County Telephone FEIN Name Address Address City/Town State ZIP County Telephone FEIN Contact NAIC code or Insurer code Insurer/TPA claim # NOTICE: Agreement should be clearly completed, (preferably typed) and uploaded in accordance with the provisions of EDI Implementation Guide. A copy must be sent to the employee. Wage information must be completed in accordance with Section 309 of the Pennsylvania Workers’ Compensation Act, and sent to the Dependent/Guardian/Personal Representative. We, the following persons, dependents of the aforementioned deceased empl\ oyee, and the undersigned employer, are parties to a compensation agreement or award which is changed because on MM DD YYYY the dependent, Died Remarried A posthumous child was born Other LIBC-339 REV 09-13 (Page 1) LIBC-339 REV 09-13 (Page 2) It is now agreed that compensation shall be payable as follows: WEEKLY RATEFROM MM-DD-YYYY THROUGHMM-DD-YYYY #WEEKS/#DAYS REASON FOR CHANGE AMOUNT $ $ $ $ $ $ $ $ $ $ $ $ $ $ The above compensation shall be payable from to \ . - - MM DD YYYY -- MM DD YYYY -- Further matters agreed upon: Date of this agreement MM DD YYYY Dependent/Guardian/Personal Representative’s signature Claims Representative’s name (typed/printed) Claims Representative’s signature Telephone 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 Info rmation Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 r a-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991 *339* Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program