Fill and Sign the Notice of Suspension for Failure to Return Form Libc 760 Pa

LIBC-762 REV 04-18 (Page 1) NOTICE OF SUSPENSION FOR FAILURE TO RETURN FORM LIBC-760 EMPLOYEE \ EMPLOYER \ \ INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) \ ATTORNEY FOR EMPLOYEE (if known) ATTORNEY FOR INSURER/EMPLOYER (if known) \ A COPY OF THIS FORM AND ATTACHMENTS ARE TO BE PROVIDED TO THE EMPLOYEE A\ ND THE EMPLOYEE’S ATTORNEY (IF KNOWN). (OVER) EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - - - DATE OF INJURY WCAIS CLAIM NUMBER MM DD YYYY Name Address Address City/Town State ZIP County Telephone FEIN Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim # First name Last name Date of birth Address Address City/Town State ZIP County Telephone Name Signature Address Address City/Town State ZIP Telephone FEIN Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number - - DATE OF THIS NOTICE: MM DD YYYY (EMPLOYEE VERIFICATION OF EMPLOYMENT, SELF-EMPLOYMENT OR CHANGE IN PHYS\ ICAL CONDITION) DEPARTMENT OF LABOR & INDUSTRYBUREAU OF WORKERS’ COMPENSATION You are hereby notified that your workers’ compensation benefits have been suspended as of due to your failure to return the Employee Verification of Employment, Self-Employment or Change in Physical Condition form (LIBC-760) which was mailed to you on . This form was due for return to the sender within 30 calendar days of its receipt. Your failure to return the completed form within this time period entitles your insurer/employer to suspend your workers’ compensation benefits under Section 311.1(g) of the Pennsylvania Workers’ Compensation Act. Your workers’ compensation benefits will immediately begin again upon your insurer/employer’s receipt of the verification form, but you will not receive reinstated benefits for the period of this suspension. In addition, failure to comply with the provisions of Section 311.1(d) may subject you to prosecution under the provisions of Article XI of the Pennsylvania Workers’ Compensation Act relating to fraud. If you did return the completed LIBC-760 within the prescribed time period, contact the forms sender (insurer/employer) immediately to clarify this matter. Attached is another copy of the Employee Verification form to assure that you have the opportunity to complete and return it promptly to stop this suspension action. You may challenge the suspension on legal grounds by filing a Petition for Reinstatement with the Pennsylvania Bureau of Workers’ Compensation at the address listed on the front. Petitions can be obtained by calling the Bureau at 1-800-482-2383. LIBC-762 REV 04-18 (Page 2) Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program - - MM DD YYYY - - MM DD YYYY *762* 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 Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 PA Relay 7-1-1 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447