Fill and Sign the Libc 100 Wc Ampamp the Injured Worker Pamphlet Pa Dli Pagov Form

DEPARTMENT OF LABOR & INDUSTRYWORKERS’ COMPENSATION OFFICE OF ADJUDICATION INFORMAL CONFERENCEAGREEMENT FORM EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY MM DD YYYY WCAIS CLAIM NUMBER EMPLOYEE \ EMPLOYER \ \ \ First name Last name Date of birth Address Address City/Town State ZIP County Telephone Name Address Address Cit y/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 # 1. This matter is currently pending on before W orkers’ Compensation Judge TYPE OF PETITION(S) NAME 2. On the parties filed a Notice of Request for an Informal Conference pursuant to Section 402.1 of the Pennsylv ania Workers’ Compensation Act. 3. An informal conference was conducted before on At that conference, the employee was was not represented by counsel, and the employer was was not represented by counsel. 4. The parties hav e agreed upon the following matters at the informal conference: MM DD YYYY ADDRES S MM DD YYYY Workers’ Compensation Judge LIBC-754 REV 09-13 (Page 1) - - - - -- -- If necessary, attach separate pages, each signed by all parties, to state fully the matters agreed upon at the conference. If a Notice of Compensation Payable, Agreement for Compensation, or Supplemental Agreement has/have been executed, attach such document(s). Complete all required EDI tr ansactions in accorda nce with the pro visions of the EDI Implementation Guide. Date of this agreement MM DD YYYY Employee’s signature Insurer/Employer’s Agent’s signature Employee’s name (typed/printed) Insurer/Employer’s Agent’s name (typed/printed) Employee’s Attorney’s signature Insurer/Employer’s Attorney’s signature Employee’s Attorney’s name (typed/printed) Insurer/Employer’s Attorney’s name (typed/printed) 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 Services 717.772.3702 Claims Informatio n Services toll-free inside P A: 800.482.2383 local & outside P A: 717.772.4447Hearing Impaired toll-free inside P A TTY: 800.362.4228 local & outside P A TTY: 717.772.4991Email ra-li-bwc -helpline@pa.gov -- *754* Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program LIBC-754 REV 09-13 (Page 2)