Fill and Sign the Notice of Claim Against Uninsured Employer Pa Dli Pagov Form

\ \ \ \ \ department of labor & industry bureau of WorKers’ Compensation NOTICE OF WORKERS’ COMPENSATION BENEFIT OFFSET EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone DATE OF THIS NOTICE: - - MM DD YYYY 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 NAIC code or Insurer code Insurer/TP A claim # ATTORNEY FOR EMPLOYEE (if known) 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 Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number A COPY OF THIS FORM AND ATTACHMENTS ARE TO BE PROVIDED TO THE EMPLOYEE A\ ND THE EMPLOYEE’S ATTORNEY (IF KNOWN). (OVER) LIBC-761 REV 09-13 (Page 1) You are hereby noti�ed that the workers’ compensation insurance carrier/employer (speci�ed previously) is taking a credit that will offset your workers’ compensation wage-loss bene�ts 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 �le for this reimbursement after the end of the calendar tax year. Your offset is for the following: Old Age Social Security bene�ts 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 bene�t.) Unemployment compensation bene�ts. 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 bene�ts. Pension bene�ts to the extent funded by the employer directly liable for the payment of your workers’ compensation bene�ts 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 bene�ts 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 bene�t is $ , paid: Weekly Bi-weekly Other (specify): - - The offset credit of $ will be deducted from this amount beginning on: , resulting MM DD YYYY in your receiving $ workers’ compensation bene�t payments. - - An ending date of has been established for this offset or a portion of it to recoup prior offsetable MM DD YYYY bene�ts you received. After that date you will continue to receive reduced workers’ compensation bene�ts in the amount of $ per payment based on your continuing receipt of offsettable bene�ts. An ending date cannot yet be established for this offset due to the continuing nature of your bene�ts 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 bene�ts. 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 �ling a Petition to Review Compensation Bene�t 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 �ling 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 Claims Info rmation Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 r a-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991 *761* Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program LIBC-761 REV 09-13 (Page 2)