Fill and Sign the If Self Insured Form

\ \ \ \ \ DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION NOTICE OF REQUEST FOR AN INFORMAL CONFERENCE EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone WCOA USE ONLY Date �ling received Date of conference - - - - MM DD YYYY MM DD YYYY Informal conference judge (Print) Was a time extension granted? Yes No Was a resolution reached? Yes No Partial 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 Contact NAIC code or Insurer code Insurer/TPA claim # Pursuant to section 402.1 of the Act, the parties herewith request that \ the Department schedule an informal conference in the above case. The employee will be represented by an attorney at the informal conference: Yes No Employee counsel Employer counsel Adjudicating judge Suggested informal conference judge (if agreed upon) Last name Last name Last name Last name First name First name First name First name PA Attorney ID number P A Attorney ID number Pending petition(s): N otice: This notice must be �lled out as fully as possible. The original must be sent to the workers’ compensation judge (adjudicating judge) who has the assigned petition. If there is no pending petition and one is attached, then �le it with the Workers’ Compensation Of�ce of Adjudication, 1010 N. Seventh St, Suite 202 Harrisburg, PA, 17102-1400. You must send a copy to all other parties, and to the attorneys of all other parties, if 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. Date of this notice COUNSEL FOR PARTY SUBMITTING REQUEST: Attorney’s name PA Attorney ID number Firm name Attorney’s signature Address Attorney’s name (typed/printed) Address City/Town State ZIP Employee/Dependent/Guardian/Personal Representative signature Telephone Telephone LIBC-753 REV 09-13 (Page 1) - - MM DD YYYY INSTRUCTIONS AND PROCEDURES 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.go v 717.772.3702 local & outside PA: 717.772.4447 local & outside PA T TY: 717.772.4991 *753* Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program LIBC-753 REV 09-13 (Page 2)