Fill and Sign the Notification of Suspension or Modification Pursuant to Form

\ \ \ \ department of labor & industry bureau of workers’ compensation NOTIfICATION Of SUSPENSION OR MODIfICATION PURSUANT TO §§ 413 (c) & (d) - - DATE OF NOTIFICATION MM DD YYYY 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 INSTRUCTIONS This form must be completed, notarized and either uploaded in WCAIS or mailed to the Bureau of Workers’ Compensation (BWC), 1171 South Cameron Street, Room 103, Harrisburg, PA 17104-2501. This form must be mailed to the employee and �led with BWC within seven days of a suspension or modi�cation of bene�ts under the provisions of the Workers’ Compensation Act. 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/TPA claim # You are noti�ed that because you returned to work on , your weekly disability bene�ts for this - - injury have been: MM DD YYYY - - Suspended effective because you have returned to work at earnings equal to or greater than your MM DD YYYY time-of-injury earnings of $ . OR Modi�ed to the rate of $ per week, effective because you returned - - to work at earnings less than your time-of-injury earnings. MM DD YYYY INSURER’S AffIDAVIT I attest or af�rm that the statements contained herein are true and correct to the best of my knowledge, information and belief. af�x seal here Claims representative’s signature SUBSCRIBED AND SWORN TO (OR AFFIRMED) BEFORE ME THIS Claims representative’s name (typed/printed) DAY OF , Phone number Signa ture of notary NOTE TO EMPLOYEE: If you do not agree with this action and wish to challenge it, please read the instructions under EMPLOYEE CHALLENGE on the back of this form. LIBC-751 REV 09-13 (Page 1) Weekly wages must be computed in accordance with the Pennsylvania Workers’ Compensation Act. CALCULATION for partial compensation rate (to be completed for modi�cation). The employee’s new partial compensation rate is based on the claimant’s present weekly earning a\ nd is calculated as follows: Calculation: Average weekly wage at time of injury minus: Present weekly earnings Subtotal x 2/3 = New partial compensation rate (Subject to the maximum bene�t) EMPLOYEE CHALLENGE: If you do not agree with this action, you must challenge it within (20) days of the date you receive this notice. Challenge it online at www.WCAIS.pa.gov. Choose �le petition action, choose challenge and the claim number you want to challenge. In the alternative, you may challenge by checking the box below, signing this form and mailing it to the Pennsylvania Department of Labor & Industry, Workers’ Compensation Of�ce of Adjudication (WCOA), 1010 N 7th Street, Suite 201, Harrisburg, PA 17102-1400. This material must be �led with the (WCOA) within (20) days from the date you received it. If you do not challenge this action within (20) days of the date you receive this notice, you will be deemed to have admitted that you agree with the action taken on this form. In that case, this notice will have the same binding effect as a fully executed Supplemental Agreement for the suspension or modi�cation of bene�ts. I do not agree with the action taken by my employer. I request a special supersedeas hearing (a hearing on whether my workers’ compensation bene�ts can be reduced or stopped) before a Workers’ Compensation Judge. A hearing is requested to be conducted in accordance with Sections 413 (c) & (d) of the P ennsylvania Workers’ Compensation Act. (if the employee has legal counsel, complete below.) Employee’s signature A ttorney’s name Address PA attorney ID# Address Name of �rm City/Town State ZIP Address County Address Telephone City/Town State ZIP (Employee to complete if different from information provided by employer) Telephone 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 Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991 *751* Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program LIBC-751 REV 09-13 (Page 2)