Fill and Sign the Pennsylvania Notice Compensation Form

                                                                                                                                                                                                                 Check only if compensation for medical treatment (medical only, no lose of wages) will be paid subject to the Workers' Compensation Act.                                     and explain on back of this form. 4. Payments will hereafter be made: Weekly Biweekly Other (Specify):                    days for loss or loss of use of                                                   Name of Claims Representative                   EMPLOYEE SOCIAL SECURITY NUMBER COMMONWEALTH OF PENNSYLVANIABUREAU OF WORKERS' COMPENSATION1171 CAMERON STREET, ROOM 103 HARRISBURG PA 17104-2501(TOLL FREE) 800-482-2383 NOTICE OF COMPENSATION PAYABLE DATE OF INJURY DATE OF NOTICE MONTH DAY YEAR PA BWC CLAIM NUMBER (IF KNOWN) MONTH DAY YEAR EMPLOYEE EMPLOYER First Name Name Last Name Address Address Address Address City/Town State Zip City/Town State Zip County County Telephone FEIN Telephone INSURER or THIRD PARTY ADMINISTRATOR (if self insured) INJURY INFORMATION Name Body Part(s) affected Address Type of Injury Address Description of Injury City/Town State Zip Telephone Bureau Code Claim # FEIN Check if Occupational Disease NOTICE TO EMPLOYER This Notice should be clearly completed, (preferably typed) and mailed to the. Bureau at the. address in the. upper left cornerA copy must be sent to the. injured employee with the. first payment of compensation.NOTICE TO EMPLOYEE: If any questions arise regarding these. payments, contact the. representative named at the. bottom of this Notice. If you cannotresolve a problem with the employer representative., you may call the Bureau at 800-482-2383. Compensation is payable, as follows: Compensation for medical treatment is payable. from date of injury.For compensation for medical treatment only, you should not complete numbers 1 through 5. 1. Weekly compensation rate. $ . . MONTH DAY YEAR 2. Payments begin on Based on an average weekly wage. of $(Compensation for loss of wages is payable for first 7 days only if disability extends14 or more days; compensation for medical treatment is payable. from the date, ofinjury.) MONTH DAY YEAR 3. Date first check mailed If the date exceeds the. 21 -Rule, check this box Any termination, suspension or modification of these payments must be made by agreement, final receipt, administrative or judicial determination, or asotherwise provided in the Workers' Compensation Act or Regulations of the Department. 5. If injury involves loss under Section 306(c) (except for disfigurement of the head, face, or neck) and employee has returned to work, complete the following information. (a) Compensation is payable for weeks MONTH DAY YEAR (b) Employee. returned to work without loss of income on (c) Healing period payable for weeks days (Up to (b) above and subject to 7-day waiting period) (d) Total (a) and (c) payable weeks days (e) Credit taken for disability benefits paid $ . 495 0903 Phone Number Signature of Claims Representative LIBC-495 REV 9-03 (OVER)      6. Remarks Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers'Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165. LIBC - 495 REV 9-03