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Pennsylvania Workers Compensation and Workplace Safety

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CLAIM PETITION FOR ADDITIONAL COMPENSATION FROM THE SUBSEQUENT INJURY FUND PURSUANT TO SECTION 306.1 OF THE WORKERS’ COMPENSATION ACT

DEPARTMENT OF LABOR & INDUSTRY
WORKERS’ COMPENSATION OFFICE OF ADJUDICATION
LIBC-375 REV 09-13

EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER

DATE OF INJURY

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

Telephone

EMPLOYER

Name

Address

Address

City/Town
  State   ZIP

County

Telephone
  FEIN

INJURY INFORMATION

Part of body injured

Nature of injury

Accident/injury description narrative

Check if occupational disease

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 Office of Chief Counsel

1171 South Cameron St

Harrisburg, PA 17104-2501

An employee seeking additional compensation from the Subsequent Injury fund should file this petition if the employee has previously incurred (through injury or otherwise) permanent partial disability, 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.

1. Date of first (prior) loss or loss of use of, one hand, arm, foot, leg or eye, resulting in permanent partial disability.

2. Complete description of first (prior) loss or loss of use.

a. Was this loss or loss of use work-related? Yes No   If Yes, name and address of employer:

3. Date of second (subsequent) loss, or loss of use of another hand, arm, foot, leg or eye, resulting in total disability.

4. Complete description of second (subsequent) loss or loss of use injury.

a. Was this loss of use injury work-related? Yes No   If yes, name and address of employer:

5. Is there pending workers’ compensation litigation or a previous Workers’ Compensation Judge’s decision regarding the second (subsequent) loss or loss or use injury? Yes No

a. If yes, when was the claim petition filed?

b. If a Workers’ Compensation Judge’s decision was rendered, what was the circulation date of the decision?

c. Was there an award of benefits for a specific loss or loss of use? Yes No

i. If yes, how many weeks of benefits were awarded?

ii. On what date did the specific loss award commence?

6. What were your wages at the time of the second (subsequent) injury? $ Hour Day Week

7. If you have returned to work since the second (subsequent) injury, are you earning More Same Less than you were at the time of the injury? Current earnings $ Hour Day Week

8. Are you entitled to receive any other benefits by reason of your increased disability, either from any state or federal fund or agency? Yes No   If yes, please list.

PLEASE ENTER MY APPEARANCE FOR PETITIONER:

Attorney’s name

PA Attorney ID number

Firm name

Address

Address

City/Town State ZIP

Telephone

Date of petition

Attorney’s signature

Notice: This petition must be filled out as fully as possible. The original must be sent to the Workers’ Compensation Office 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 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 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

Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program

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What the Pennsylvania Workers Compensation and Workplace Safety document covers

The Pennsylvania Workers Compensation and Workplace Safety document explains how employees, employers, and insurers record and report work-related injuries, illnesses, and safety incidents under Pennsylvania law. It covers claim initiation, employer reporting duties, medical treatment documentation, and administrative steps used by the Pennsylvania Department of Labor & Industry and insurance carriers to assess benefits. The form captures incident details, witness information, treating providers, and wage data used to determine eligibility and compensation. Accurate completion supports timely care, preserves legal rights, and helps employers meet statutory obligations.

Why accurate completion matters for benefits and compliance

Completing the Pennsylvania Workers Compensation and Workplace Safety document correctly preserves employee benefits, ensures prompt medical treatment, and reduces employer exposure to penalties and contested claims. Precise reporting accelerates insurer review and supports accurate benefit determinations under state law.

Why accurate completion matters for benefits and compliance

Who typically prepares and signs these workers' compensation forms

Common users of the Pennsylvania Workers Compensation and Workplace Safety forms include employers, human resources staff, claims managers, and medical providers involved in workplace injury reporting.

  • Employers and HR: prepare incident reports and file initial employer reports with insurers.
  • Employees: report injuries, provide eyewitness names, and document medical treatment promptly.
  • Medical providers: submit treatment records and work restrictions that support benefit claims.

Accurate completion reduces disputes, speeds claims processing, and creates an auditable record for employers, insurers, and regulators.

Step-by-step: complete and submit the workers' comp form

Follow these steps to complete and submit the Pennsylvania Workers Compensation and Workplace Safety document accurately.

  • 01
    Collect details: Gather employee, incident, witness, and wage information before starting.
  • 02
    Complete fields: Fill mandatory fields, use MM/DD/YYYY dates, and avoid abbreviations.
  • 03
    Attach records: Upload medical reports, wage statements, and employer incident narratives as PDFs.
  • 04
    Submit: Send to insurer and file with Pennsylvania L&I or other required agency.

How the form moves through employer, insurer, and agency workflows

This document flows from employee to employer, insurer, and state agency as part of the workers' compensation process.

  • Employee to Employer: Employee reports injury and completes initial form.
  • Employer to Insurer: Employer files claim with their workers' compensation carrier.
  • Insurer Investigation: Insurer reviews records and authorizes treatment or issues a determination.
  • State Reporting: File required forms with Pennsylvania Department of Labor & Industry when mandated.

Configure an online workflow to collect and route claims

Configure an online workflow to collect, sign, and route workers' compensation forms securely.

Field Configuration
Signature field configuration and options Set as required; capture timestamp and signer IP for audit.
Conditional attachments and supporting records Require medical reports when certain injury codes are selected.
Advanced signer authentication settings Enable SMS codes or knowledge-based authentication for higher assurance.
Automated notifications and reminders Send alerts to adjuster, HR, and employee on routing triggers.

Digital signing, integrations, and security considerations

Use an eSignature platform that supports PDF, DOCX, mobile signing, and secure audit trails for legal compliance and recordkeeping.

  • Supported formats: PDF, DOCX, and HTML accepted.
  • Integrations: Salesforce, NetSuite, Google Workspace supported.
  • Security standards: TLS 1.2/1.3 and AES-256 encryption.

Core elements to include on a professional claim form

Key elements of the Pennsylvania Workers Compensation and Workplace Safety document guide benefit eligibility, employer obligations, and claims administration processes.

Employer details

Provide legal employer name, FEIN, business address, and claims contact. Accurate employer data ties the claim to the correct insurance policy and reporting unit.

Employee details

Record full legal name, date of birth, contact information, occupation, and SSN or TIN. Precise identifiers speed verification and benefits determination.

Injury description

Document mechanism, time, date, body part(s), and witness names with a factual chronology. Clear narratives reduce disputes during insurer review and hearings.

Medical information

List treating providers, dates of service, diagnoses, procedures, and work restrictions. Attach medical records and diagnostic codes to support ongoing care authorization.

Wage and earnings

Provide recent wages, hours, pay period, and employer-paid benefits used to calculate compensation rates and loss of earning capacity.

Claim determination

Record insurer decision, compensation awarded, claim number, and appeals history to maintain an auditable trail for employers and regulators.

Essential data fields and short-format requirements

Employer Name: Legal business name.
FEIN: Nine-digit FEIN.
Employee Name: Full legal name.
SSN/TIN: SSN or taxpayer ID.
Date of Injury: MM/DD/YYYY format.
Claim Number: Insurer-assigned ID.

Common mistakes that delay claims or create exposure

  • Missing or inconsistent dates (injury, treatment) force insurers to request clarifications and delay benefits for the claimant.
  • Vague injury descriptions without specifics or witness names lead to incomplete investigations and potential denials.
  • Failing to attach medical documentation or wage records results in repeated requests and slower claim adjudication.
  • Incorrect employer FEIN or payer information misroutes claims and can complicate tax reporting and premium allocation.

Penalties and risks from incorrect or late submissions

Delayed benefits: Employee benefit payments postponed.
Fines and penalties: State fines or administrative penalties.
Claim denial: Potential denial for lack of proof.
Increased premiums: Higher insurance costs for employer.
Legal exposure: Civil litigation risk increases.
Criminal liability: False statements risk prosecution.

Timelines and deadlines to protect rights and compliance

Timely reporting and filing reduce penalties and protect benefit rights; deadlines vary by state, insurer policy, and claim type.

Employee reporting timeframe:

Report injury to employer as soon as possible; check specific state deadlines.

Employer reporting to insurer:

Report claims promptly per carrier instructions and state rules to avoid late reporting issues.

Medical authorization timing:

Seek treatment immediately; preauthorization may be required for non-emergency care.

Statute of limitations:

Time limits for filing claims vary by jurisdiction; consult state statute or counsel.

Appeals and hearings deadlines:

Deadlines for appeals and hearings are strict; missing a deadline can forfeit rights.

Practical examples of moving claims paperwork online

Real organizations have streamlined claims intake and compliance by digitizing workers' compensation forms and attachments.

Optica Ventures — COO

The interface is simple and easy-to-use for our team; more importantly, it is just as easy for our customers.

  • Reduced turnaround time.
  • Optica replaced paper workflows with a digital intake process to minimize back-and-forth, capture complete incident data at source, and provide a consistent audit trail for insurer reviews and internal records.

Fertility Centers of Illinois — Founder

The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company.

  • Streamlined integrations.
  • The center used integrated eSignature workflows to attach medical records, route authorizations to insurers, and maintain secure, HIPAA-aware document trails tied to each patient claim.

Comparison: eSignature options relevant to workers' compensation workflows

Pricing and basic capabilities vary across eSignature vendors; signNow appears first as a cost-conscious option with enterprise features and compliance support.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year No cap No cap No cap

Frequently asked questions about electronic handling and signature validity

Answers address legal validity, notarization, state filing, correcting errors, and secure eSubmission practices for workers' compensation documents.


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