Fill and Sign the Petition Tofor Form

\ \ \ \ \ DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION 2)),&(OF ADJUDICATION PETITION TO/FOR: (Check any that apply) EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - Modify compensation bene�ts (Reduce/increase amount of workers’ compensation) Penalties (For violation of the act, rules and regulations) Reinstate compensation bene�ts Review compensation bene�ts Review compensation bene�ts offset Review medical treatment and/or billing DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY Seek approval of a compromise and release agreement (Ask judge to approve settlement) Set aside �nal receipt (Ask judge to set aside agreement to stop compensation) Suspend compensation bene�ts Terminate compensation: Based upon physician’s af�davit, a special supersedeas hearing to be scheduled Terminate compensation bene�ts (Employee fully recovered without any disability) This petition is �led on behalf of: Employee Employer/Insurer 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 Provide the following information if Employer has accepted liability for this injury: Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN VS. INSURER, FUND 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 # “FUND” SHALL MEAN THE UNINSURED EMPLOYERS \ GUARANTY FUND, SUBSEQUENT INJURY FUND, \ SELF-INSURANCE GUARANTY FUND OR \ PRE-SELF-INSURANCE GUARANTY FUND. TO YOUR HONORABLE JUDGE: The above petitioner requests the work ers’ compensation judge to order the above action as of for the following reason(s). MM DD YYYY 1. Full recovery 10. Medical bills unpaid 2. Speci�c job offered 11. Medical bills not related 3. Work generally available 12. Worsening of condition 4. Able to return to unrestricted work 13. Injury causing decreased earning power 5. Has returned to work 14. Section 314 order violated 6. Reasonable treatment refused 15. Voluntary withdrawal from workforce 7. Resolution to speci�c loss 16. Violation of the act, rules and regulations 8. Incorrect description of injury 17. Subrogation, credit or offset for 9. Incorrect average weekly wage UC Social Security Third party recovery S&A Pension - - LIBC-378 REV 09-13 (Page 1) 18. Other Compensation bene�ts being paid have been paid based on a: Notice of compensation payable dated Agreement dated Supplemental agreement dated MM MM MM - - - DD DD DD - - - YYYY YYYY YYYY Judge’s order dated Board order dated Court order dated MM MM MM - - - DD DD DD - - - YYYY YYYY YYYY This is an Act 46 (�re�ghter cancer) claim Is supersedeas being requested pursuant to Section 413(A.2)? If yes, list reasons: Yes No Average weekly wage $ Applicable weekly total disability rate $ Date of most recent payment - - Amount $ . . . MM DD YYYY PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney’s name PA attorney ID number Firm name Address Address City/Town State ZIP Telephone Petitioner or Representative’s signature Petitioner or Representative’s name (typed/printed) COUNSEL FOR RESPONDENT (if known) : Attorney’s name PA attorney ID number Firm name Address Address City/Town State ZIP Telephone Date of petition - - MM DD YYYY N otice: This petition must be �lled out as fully as possible. If not �ling electronically, 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 send a copy to all other parties, and to 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 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 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 *378* Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program LIBC-378 REV 09-13 (Page 2)