Fill and Sign the Pennsylvania Workers Compensation and Workplace Safety Form

\ \ \ DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION LIBC-375 REV 09-13 (Page 1) CLAIM PETITION FOR ADDITIONAL COMPENSATION FROM THE SUBSEQUENT INJURY FUND PURSUANT TO SECTION 306.1 OF THE WORKERS’ COMPENSATION ACT EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - DATE OF INJURY MM DD YYYY WCAIS CLAIM NUMBER - - EMPLOYEE First name Last name Date of birth If deceased - Dependent/Guardian/Personal Representative First name Last name Address Address City/Town State ZIP County T elephone INJURY INFORMATION Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease EMPLOYER Name Address Address City/T own State ZIP County Telephone FEIN \ VS. 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 # AND Commonwealth of Pennsylvania Department of Labor & Industry c/o Of�ce of Chief Counsel 1171 South Cameron St Harrisburg, PA 17104-2501 An employee seeking additional compensation from the Subsequent Injury fund should �le this petition if the employee has previously incurred (through injury or otherwise) permanent partial di\ sability, through the loss, or loss of use of, one hand, one arm, one foot, one leg or one eye, and incurs total disability through a subsequent injury, causing loss, or loss of use of, another hand, arm, foot, leg or eye. - - - - - - - - - - Attorney’s name PA Attorney ID number Firm name Address Address City/Town State ZIP Telephone - - Date of petition MM DD YYYY Attorney’s signature N otice: This petition must be �lled out as fully as possible. The original must be sent to the Workers’ Compensation Of�ce of Adjudication, 1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. You must serve a copy on all other parties, and on the attorneys of all other parties, if the attorneys are known. A Proof of Service must be attached. A Proof of Service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if known. Questions regarding the completion of this form may be directed to the Bureau of Workers’ Compensation Claims Information Services. 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 *375* Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program LIBC-375 REV 09-13 (Page 2)