Fill and Sign the Notice of Change of Workers Compensation Disability Pa Dli Form

NOTICE COMMONWEALTH OF PENNSYLVANIADEPARTMENT OF LABOR AND INDUSTRYBUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET ROOM 103 HARRISBURG PA 17104-2501(TOLL FREE) 800-482-2383 STOPPING TEMPORARY COMPENSATION Employee Employer DATE OF THIS NOTICE: MM DD YYYY NOTICE TO EMPLOYEE: This notice is being sent because payment of temporary compensation is being stopped as of The payment of temporary compensation does not mean that your employer assumed responsibility for your injury. Your employer and you retain all rights, defenses and obligations with regard to the claim. Further, the payment of temporary compensation may not be used to support a claim for benefits in a future proceeding. WE HAVE ACCEPTED RESPONSIBILITY FOR YOUR CLAIM, AND ATTACHED IS A NOTICE OF COMPENSATION PAYABLE OR AN AGREEMENT FOR COMPENSATION, OR, WE HAVE DECIDED NOT TO ACCEPT LIABILITY AND ATTACHED IS A NOTICE OF WORKERS' COMPENSATION DENIAL. IF YOU BELIEVE YOU SUFFERED A WORK-RELATED INJURY, YOU WILL BE REQUIRED TO FILE A CLAIM PETITION WITH THE BUREAU OF WORKERS' COMPENSATION IN ORDER TO PROTECT YOUR FUTURE RIGHTS. You have three (3) years from the date of injury or discovery of your condition to file a Claim Petition for benefits. Since time limits can vary depending on the facts of your situation, you may wish to contact an attorney if you believe you may have a claim. Authorized Agent for Insurer or TPA (if self-insured) The original must be filed with the Bureau of Workers' Compensation. This notice must be sent and filed no later than five (5) days after the last payment of tempo- rary compensation. A copy of this notice is to be sent to the injured employee. Any individual filing misleading or incomplete information knowingly and with intent to defraud 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 of 1994. LIBC-502 REV 12-97 Last Name First Name Telephone Signature Last Name First Name Name If deceased - Dependent, Guardian Zip Code Street 2 County City/Town Zip Code FEIN Telephone Telephone County Insurer or Third Party Administrator (if self-insured) Name Zip Code Telephone Bureau Code County Claim Number FEIN Street 1 Last Name First Name State Street 2 City/Town Street 1 State Street 2 City/Town Street 1 State Social Security Number: Date of Injury: PA BWC Claim Number: (IF KNOWN) DD YYYY MM 502 1297-1 0