Fill and Sign the Justia Notice of Compensation Payable Pennsylvania Form

NOTICE OF TEMPORARY COMPENSATION PAYABLE 1171 S. CAMERON STREET, ROOM 103HARRISBURG PA 17104-2501(TOLL FREE) 800-482-2383 DATE OF NOTICE MONTH YEAR DAY EMPLOYER EMPLOYEE Name First Name Last Name Address Address Address Address State City/Town Zip State Zip City/Town County County Telephone FEIN Telephone INSURER or THIRD PARTY ADMINISTRATOR (if self insured) Name INJURY INFORMATION Address Body Part(s) affected Address Type of Injury City/Town Zip State Description of Injury Bureau Code Telephone County Check if Occupational Disease FEIN Claim # NOTICE TO EMPLOYER: A copy of this Notice is to be sent to the injured employee with the first payment of temporary compensation, the original filed With the Department of Labor and Industry. Ninety days begins on the first day of disability. The employers/insurers failure to file a notice advising the employee that the employer is ceasing temporary compensation shall be deemed an admission of liability, and this notice shall be converted to a Notice ofCompensation Payable. NOTICE TO EMPLOYEE: This Notice of temporary compensation payments is for a period of up to 90 days and is not an admission by your employerthat it is responsible for your injury. If any questions arise, contact the representative at the bottom of this Notice. If you need further information, call the Bureau at 800-482-2383. Compensation is payable as follows: 1. Weekly compensation rate $ Based on an average weekly wage of $ YEAR MONTH DAY MONTH DAY YEARNinety day period ends on 2. Payments begin on Biweekly Other (Specify): 3. Payments will hereafter be made: Weekly until payments cease or the ninety-day maximum period for temporary compensation expires. 4. Remarks: Name of Claims Representative 501 1197-1 Signature of Claims Representative Phone Number Any individual filing misleading or incomplete information knowingly and with intent todefraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165. LIBC-501 REV 11-97 DEPARTMENT OF LABOR AND INDUSTRYCOMMONWEALTH OF PENNSYLVANIA BUREAU OF WORKERS' COMPENSATION EMPLOYEE SOCIAL SECURITY NUMBER DATE OF INJURY MONTH DAY YEAR PA BWC CLAIM NUMBER (IF KNOWN) . .