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\ \ \ dep dep artment of labor & industr artment of labor & industr y y bureau of w bureau of w orkers’ c orkers’ compensa ompensation tion EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE VERIFICATION OF EMPLOYMENT, SELF-EMPLOYMENT OR CHANgE IN PHYSICAL CONDITION EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone 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/TPA claim # INSTRUCTIONS TO EMPLOYEE: DO NOT RETURN THIS FORM TO THE BUREAU OF WORKERS’ COMPENSATION. COMPLETED FORM MUST BE RETURNED TO THE PARTY WHO SENT THE FORM TO YOU WITHIN 30 DAYS OF YOUR RECEIPT OF THIS FORM. IF YOU DO NOT COMPLETE AND RETURN THIS FORM TO THE PARTY WHO SENT IT TO YOU WITHIN 30 DAYS IT MAY RESULT IN A SUSPENSION OF YOUR COMPENSATION BENEFITS AS PROVIDED BY SECTION 311.1(g) OF THE WC ACT, AS WELL AS PROSECUTION FOR FRAUD UNDER ARTICLE XI OF THE WC ACT. YOU MAY BE REQUIRED TO COMPLETE AND RETURN THIS FORM EVERY SIX MONTHS. INSTRUCTIONS TO EMPLOYEE: Section 311.1(d) of the Workers’ Compensation Act requires employees who are receiving workers’ compensation, or have �led a petition to receive workers’ compensation, to verify employment, self-employment, wages and changes to physical condition. 1. Are you currently employed by any employer other than the employer listed above? Yes No 2. Are you currently self-employed? Yes No 3. Have you been employed or self-employed at any time while receiving workers’ compensation bene�ts? Yes No 4. Has your physical condition (caused by your injury) changed? Yes No 5. Is there other information you are aware of that is relevant in determining your entitlement to, or amount of compensation? Yes No (OVER) LIBC-760 REV 09-13 (Page 1) 6. Names of employers for whom you have worked since your date of injury: Name Address Address City/Town State ZIP Period of employment: From To Amount of wages $ - - MM DD - - MM DD . YYYY YYYY Name Address Address City/Town State ZIP Period of employment: From To Amount of wages $ - - MM DD - - MM DD . YYYY YYYY Name Address Address City/Town State ZIP Period of employment: - - From MM DD YYYY - - MM DD YYYY To Amount of wages $ . IF SELF-EMPLOYED From MM - DD - YYYY To MM - DD - YYYY Amount of wages $ . I verify that this information is true and correct based upon my knowledge, information and belief. I understand false statements are subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsi�cation to authorities. Employee First name Last name DATE OF NOTICE - - Signature MM DD YYYY 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 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 *760* Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program LIBC-760 REV 09-13 (Page 2)