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Notice of Claim Against Uninsured Employer

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NOTICE OF WORKERS' COMPENSATION BENEFIT OFFSET

Department of Labor & Industry
Bureau of Workers' Compensation

Employee Social Security Number or WC ID Number

Date of Injury

WCAIS Claim Number

Employee

First name

Last name

Date of birth

Address

Address

City/Town State ZIP

County

Telephone

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

NAIC code or Insurer code

Insurer/TPA claim #

Attorney for Employee (if known)

Name

Firm name

Address

Address

City/Town State ZIP

Telephone PA Attorney ID number

Attorney for Insurer/Employer (if known)

Name

Firm name

Address

Address

City/Town State ZIP

Telephone PA Attorney ID number

Name

Signature

Address

Address

City/Town State ZIP

Telephone FEIN

You are hereby notified that the workers’ compensation insurance carrier/employer (specified previously) is taking a credit that will offset your workers’ compensation wage-loss benefits as authorized by Section 204 of the Pennsylvania Workers’ Compensation Act.

If you pay federal, state, or local taxes on an offset amount, provide a written statement to your employer/insurer showing the amount of the taxes you paid on the offset to receive reimbursement for these taxes. You may file for this reimbursement after the end of the calendar tax year.

Your offset is for the following:

Old Age Social Security benefits which you began to receive following an injury which occurred on or after June 24, 1996. (This offset is for one-half or 50% of this Social Security benefit.)

Unemployment compensation benefits. If you are eventually found to be ineligible for the unemployment compensation payment, you must notify the above insurer/employer which shall reinstate the offset workers’ compensation benefits.

Pension benefits to the extent funded by the employer directly liable for the payment of your workers’ compensation benefits due to an injury occurring on or after June 24, 1996. This employer can also take credit for investment income which is attributable to this contribution.

Severance benefits paid by the employer directly liable for compensation and received subsequent to a work-related injury occurring on or after June 24, 1996.

Your current workers’ compensation wage-loss benefit is $ ,

paid: Weekly Bi-weekly Other (specify):

The offset credit of $ will be deducted from this amount beginning on: , resulting in your receiving $ workers’ compensation benefit payments.

An ending date of has been established for this offset or a portion of it to recoup prior offsetable benefits you received. After that date you will continue to receive reduced workers’ compensation benefits in the amount of $ per payment based on your continuing receipt of offsettable benefits.

An ending date cannot yet be established for this offset due to the continuing nature of your benefits which are applicable to an offset.

You will receive an additional notice if a change occurs in this offset. This form is to provide you with at least twenty (20) calendar day’s notice of this offset prior to a change in your workers’ compensation benefits. The offset was calculated as follows and additional calculations may be attached:

Attached are the following documents supporting the basis for this offset:

You may challenge this offset by filing a Petition to Review Compensation Benefit Offset with the Pennsylvania Department of Labor & Industry, Bureau of Workers’ Compensation. Petitions can be obtained by calling the Bureau at 1-800-482-2383.

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 Information Services

toll-free inside PA: 800.482.2383
local & outside PA: 717.772.4447

Hearing Impaired

toll-free inside PA TTY: 800.362.4228
local & outside PA TTY: 717.772.4991

Email

ra-li-bwc-helpline@pa.gov

Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program

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What the Notice of Claim Against Uninsured Employer Is

Notice of Claim Against Uninsured Employer is a formal written submission used when an injured worker seeks benefits or recovery where the employer lacks workers’ compensation coverage or the coverage is disputed. The notice records claimant identity, employer details, date and nature of injury, and any immediate medical treatment. Filing the notice opens an administrative record with the appropriate state workers’ compensation authority or uninsured employer fund and starts the review, investigation, or benefit determination process under applicable state statutes and agency rules.

Why a Clear Notice Matters

Filing a timely and accurate Notice of Claim Against Uninsured Employer preserves legal rights, creates a documented claim file, and triggers agency review or fund eligibility. Proper notices help secure medical care, document wage loss, and support later administrative or civil recovery options.

Why a Clear Notice Matters

Who Typically Prepares and Submits This Notice

Typical filers include injured workers, attorneys, and representatives submitting claims to workers’ compensation or uninsured employer funds.

  • Injured workers submitting first notice and medical documentation to the state agency.
  • Labor or claims attorneys protecting clients’ rights and preserving statutory deadlines.
  • Third-party administrators or insurers processing claims on behalf of state uninsured employer funds.

Identify your role clearly and attach appropriate supporting evidence to ensure correct routing and timely processing by the receiving agency.

Step-by-Step: Prepare and File the Notice

Follow this sequence to complete and submit a Notice of Claim Against Uninsured Employer accurately and within required timeframes.

  • 01
    Prepare Details: Gather personal, employer, injury, and medical treatment information.
  • 02
    Complete Form: Enter dates, employer name, job title, and an incident description.
  • 03
    Attach Evidence: Include medical records, bills, witness statements, and employer correspondence.
  • 04
    Submit File: Send to the correct state agency or uninsured employer fund address.

Essential Sections to Include in a Professional Notice

A complete Notice of Claim Against Uninsured Employer groups claimant data, employer facts, incident description, medical information, loss details, and a clear signature block.

Claimant Info

Full legal name, DOB, contact details, SSN or claimant ID, and current address. Accurate identity details speed verification and contact by the agency.

Employer Details

Employer legal name, trade name, full address, known tax ID or EIN, supervisor contact, and a statement about the employer’s insurance status.

Incident Description

Date, time, location, and a concise narrative of the event, including tools, machinery, or conditions involved and witness names if available.

Medical Treatment

List treating providers, diagnoses, treatment dates, and ongoing care or restrictions. Attach emergency or clinic records when available to substantiate the claim.

Damages & Losses

Describe wage loss, lost hours, out-of-pocket medical costs, and other economic impacts with approximate amounts and supporting documentation where possible.

Signature Block

Signature, printed name, date, and preparer contact. If an attorney signs, include representation letter and bar or firm identification.

Security and Compliance Considerations

Encryption In Transit: TLS 1.2 and TLS 1.3 encryption for data transmitted
Encryption At Rest: AES-256 encryption for stored documents and data
Certifications: SOC 2 Type II, ISO 27001, PCI DSS attestations
HIPAA Support: BAA available for covered entities handling PHI
eSign Laws: Compliant with ESIGN and UETA for legal enforceability
Audit Trail: Detailed timestamps, IP addresses, and action history

Key Risks and Penalties From Errors

Missed Deadline: Loss of benefit eligibility
Incorrect Employer Info: Delayed processing or denial
Unsigned Notice: Possible rejection by agency
Insufficient Evidence: Investigation delays
Improper Signature: Authentication failure
False Statement: Criminal penalties and fines

Common Pitfalls to Avoid When Preparing the Notice

  • Submitting incomplete employer identifiers or misspelled legal names, which can misroute the claim and delay resolution for weeks or months.
  • Attaching redacted or partial medical records instead of full relevant notes and invoices, causing repeated document requests from the agency.
  • Using ambiguous incident descriptions that fail to link the injury to job duties, increasing the likelihood of denial or contested liability.
  • Relying on unsigned or informal acknowledgements from the employer rather than documented denials or insurer correspondence when available.

Configuring an Electronic Filing Workflow

Configure an electronic workflow to collect signatures, attach documents, and route the notice to the appropriate state agency or fund.

Field Configuration
Sender Email Set valid sender address and reply-to for confirmations
Signature Type Select e-signature or digital PKI based on agency requirements
Authentication Choose email link, SMS code, or knowledge-based authentication
Routing Define signer order and direct final copy to agency contacts

How Electronic Submission Typically Works

This overview shows standard routing for submitting a Notice of Claim Against Uninsured Employer to a state agency or uninsured employer fund.

  • Draft: Fill form fields and attach evidence
  • Review: Confirm accuracy and supporting documents
  • Authorize: Sign electronically with required authentication
  • File: Send to agency via eSubmit or mail

Platform and Technical Requirements for eFiling

Most agencies accept electronic filings; verify accepted file formats and authentication requirements in advance.

  • Formats Supported: PDF, DOCX, HTML generally accepted
  • Integrations: Salesforce, NetSuite, Google Workspace integrations
  • Authentication: Email link, SMS code, KBA, or SSO options

Time-Sensitive Deadlines to Track

Key deadlines vary by state; meet initial filing and response windows to preserve rights and avoid administrative dismissals.

Initial Filing Window:

File as soon as practicable and within any state statutory deadline

Agency Acknowledgment:

Expect confirmation within agency-specific processing times, often 7–30 days

Employer Response Period:

Employers typically have 20–30 days to respond or contest, depending on jurisdiction

Appeal Deadlines:

Appeal periods vary by state; missing them can forfeit rights

Statute of Limitations:

State tort or compensation statutes set long-stop filing limits and evidentiary windows

Key Milestones From Filing to Decision

Milestone timeline shows sequential stages from notice preparation through investigation and final agency determination.

01

Prepare and File

Complete the notice, attach supporting records, and submit to the correct agency

02

Agency Intake

Agency logs the claim, assigns a case number, and schedules next steps

03

Investigation & Hearing

Agency reviews evidence, may request more documents or convene a hearing

04

Decision & Remedies

Agency issues findings and may award benefits or direct civil recovery options

eSignature Vendor Pricing and Compliance Snapshot

Compare common eSignature vendor pricing, bulk send, audit trail capabilities, and HIPAA compliance relevant to Notice of Claim workflows.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial, no credit card required Trial availability and length vary by vendor Trial availability and length vary by vendor Trial availability and length vary by vendor Trial availability and length vary by vendor
Bulk Send Yes (Business Premium+) Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently Asked Questions

Answers to common questions about preparing, submitting, and validating a Notice of Claim Against Uninsured Employer.


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