Who is responsible for completing the notice?

Employers or their authorized insurers/claims administrators typically complete the notice when temporary disability benefits are approved. In contested cases legal representatives may prepare notices; always ensure an authorized signatory signs and dates the form to avoid processing delays.

Is an electronic signature acceptable on the notice?

Yes, electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided the signer consents and the record is retained. Confirm state-specific submission rules and any Bureau e-filing requirements before e-submission.

Is notarization required for the notice?

Not generally required for routine notices to pay temporary compensation, but certain attachments or local agency procedures may request notarization. Verify with the Pennsylvania Bureau of Workers' Compensation or local counsel before adding notarial acknowledgments.

Which documents should I attach to the notice?

Include medical reports supporting temporary disability, wage statements used to calculate the weekly rate, and any authorization forms. Label files clearly and use PDF format where possible to preserve metadata and timestamps for audits and administrative review.

How long should copies of the notice be retained?

Retain signed notices and supporting documentation for at least the active claim period plus three years; retain medical records for six years under HIPAA (45 CFR §164.530(j)) and follow applicable state retention rules for longer periods.

How to update the notice if payments change?

Issue an amended Notice of Temporary Compensation Payable documenting new rates or revised dates. Serve amended copies to the claimant, insurer, and the Bureau as required, and keep prior versions in the file to preserve the payment history and audit trail.

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Pennsylvania Notice of Temporary Compensation Payable

Pennsylvania Notice of Temporary Compensation Payable

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NOTICE OF TEMPORARY COMPENSATION PAYABLE

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF LABOR AND INDUSTRY

BUREAU OF WORKERS' COMPENSATION

1171 S. CAMERON STREET, ROOM 103

HARRISBURG PA 17104-2501

(TOLL FREE) 800-482-2383

EMPLOYEE SOCIAL SECURITY NUMBER

DATE OF INJURY

DATE OF NOTICE

PA BWC CLAIM NUMBER (IF KNOWN)

EMPLOYEE

First Name

Last Name

Address

City/Town

State

Zip

County

Telephone

EMPLOYER

Name

Address

City/Town

State

Zip

County

Telephone

FEIN

INJURY INFORMATION

Body Part(s) affected

Type of Injury

Description of Injury

Check if Occupational Disease

Claim #

FEIN

NOTICE TO EMPLOYER:

A copy of this Notice is to be sent to the injured employee with the first payment of temporary compensation, the original filed with the Department of Labor and Industry. Ninety days begins on the first day of disability. The employers/insurers failure to file a notice advising the employee that the employer is ceasing temporary compensation shall be deemed an admission of liability, and this notice shall be converted to a Notice of Compensation Payable.

NOTICE TO EMPLOYEE:

This Notice of temporary compensation payments is for a period of up to 90 days and is not an admission by your employer that it is responsible for your injury. If any questions arise, contact the representative at the bottom of this Notice. If you need further information, call the Bureau at 800-482-2383.

Compensation is payable as follows:

1. Weekly compensation rate $

Based on an average weekly wage of $

2. Payments begin on

Ninety day period ends on

3. Payments will hereafter be made:

Weekly Biweekly Other

until payments cease or the ninety-day maximum period for temporary compensation expires.

4. Remarks:

Name of Claims Representative

Signature of Claims Representative

Phone Number

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.

What the Pennsylvania Notice of Temporary Compensation Payable Is

The Pennsylvania Notice of Temporary Compensation Payable is a workers' compensation form used to notify an injured employee, employer, and the Bureau of Workers' Compensation that temporary disability benefits will be paid for a specified period. It documents payment start and end dates, weekly compensation rate, and the basis for entitlement. Employers or insurers complete and serve the notice following Pennsylvania Workers' Compensation procedures to ensure proper benefits, recordkeeping, and to trigger payroll and tax reporting obligations. The notice may be submitted electronically where permitted by law.

Why an Accurate Notice Matters

Using the Pennsylvania Notice of Temporary Compensation Payable establishes clear payment terms, creates an audit trail for benefits, and helps avoid disputes over eligibility or timing. Accurate notice supports compliance with Department of Labor and Insurance reporting and preserves reimbursement and subrogation rights.

Who handles and receives the notice

Employers, insurers, and claims administrators in Pennsylvania use this notice to document temporary compensation payments and inform affected parties promptly.

Employers: HR/managers tracking wage continuation and reporting benefit payments to the Bureau.
Insurers: claim examiners recording payment periods, calculating weekly rates, and coordinating medical benefits.
Employees: injured workers receiving notice of payment amounts, duration, and appeals information.

Public adjusters, attorneys, and payroll teams also rely on the notice for verification, withholding, and record retention.

Core elements to include in a professional notice

A complete Pennsylvania Notice of Temporary Compensation Payable includes payer, payee, rate, period, legal basis, and signature fields to meet statutory and administrative requirements.

Payer Information

Full legal name, insurer or employer identification, mailing and contact information, and insurer claim number to identify the source of payments and enable correspondence and audits.

Payee Details

Injured worker's legal name, address, date of birth or claimant ID, Social Security number when required, and contact details to ensure correct beneficiary payment routing.

Compensation Rate

Weekly compensation rate, basis for calculation (average weekly wage), scheduled adjustments or offsets such as partial return-to-work earnings, and reference to the statutory basis used for computation.

Payment Period

Start and anticipated end dates for temporary compensation, dates of any missed payments, frequency (weekly), and expected review or reassessment dates to establish the covered timeframe for benefits.

Legal Basis

Citation of Pennsylvania statutory or administrative authority, reference to the Workers' Compensation Act and Bureau procedures, supporting medical or wage records attached, and explanation of entitlement to temporary benefits.

Signature and Date

Signature of authorized representative, printed name, title, date signed, and contact information; electronic signatures and timestamps acceptable where permitted by ESIGN and state rules, including notation of the e-sign method used.

Required fields and essential data points

Claimant Name: Full legal name as on ID

Employer/Insurer: Legal entity and contact info

Compensation Rate: Weekly gross compensation amount

Payment Dates: Start and expected end dates

Claim Number: Insurer or bureau claim ID

Signature: Authorized signer and date

Step-by-step: complete and serve the notice

Follow the sequence below to complete and serve the notice accurately and in compliance with Pennsylvania requirements.

01

Gather Info: Collect claimant, employer, medical, and wage details.
02

Calculate Rate: Compute weekly compensation and any offsets.
03

Complete Form: Enter fields, attach supporting documents, and sign.
04

Serve Notice: Provide copies to employee, Bureau, and insurer per rules.

Configure an online workflow for notices

Configure an online workflow to prefill fields, request attachments, and route signed notices to stakeholders and records systems.

Field	Configuration
Prefill Data	Use templates or CSV import to reduce manual entry.
Required Attach	Make medical and wage PDFs mandatory uploads.
Signer Auth	Enable SMS codes or knowledge-based verification.
Destination	Auto-send signed PDFs to HR and claims storage.

Where to send the completed notice

Typical routing for the notice includes delivery to the injured worker, insurer claims file, and the Pennsylvania Bureau for administrative records.

To Employee: Email or certified mail with receipt documentation.
To Insurer: Upload to claims system and notify adjuster.
To Bureau: Submit per Bureau instructions — electronic or paper filing.
To Payroll: Send copy for withholding and tax reporting.

Technical and security requirements for electronic submission

Electronic transmission must meet authentication, encryption, and retention standards to be accepted by stakeholders and regulators.

File Formats: PDF or DOCX preferred
Integrations: Connectors for HR, claims, and storage
Security: TLS in transit, AES-256 at rest

Time-sensitive actions and typical deadlines

Key deadlines and statutory timing often affect benefits, reporting, and appeals; observe these dates to avoid penalties or delayed payments.

Provide Notice to Employee:

Send upon determination of payable temporary compensation.

File with Bureau if required:

File electronic or paper copy if Bureau requests.

Document missed payments promptly:

Report and reconcile missed or late payments within payroll cycle.

Maintain records for appeals:

Retain supporting documentation according to retention rules.

Update notice for changes:

Issue amended notice if rate or period changes occur.

Processing milestones from intake to closure

Sequential milestones show processing stages from claim intake to benefit reconciliation and closure including notice issuance and final accounting.

01

Claim Intake

Collect incident report, employer statement, and initial medical form.

02

Determination

Establish liability, compute benefit rate, authorize temporary payments.

03

Notice Issued

Serve the Notice of Temporary Compensation Payable to parties.

04

Reconciliation

Record payments, offsets, and prepare closure documents.

Common preparation mistakes to avoid

Failing to match claimant identity across records can delay payments, trigger audits, and create tax withholding errors when names or Social Security numbers are inconsistent.
Omitting supporting medical or wage documentation increases likelihood of benefit denial or administrative queries and slows processing due to requests for additional evidence.
Entering ambiguous compensation calculations or failing to specify calculation method (AWW, partial disability) leads to disputes and rework between insurer and claimant.
Using informal signature images without an audit trail or failing to obtain required consent can undermine legal enforceability under ESIGN and state electronic transaction laws.

Potential penalties and legal risks

Late Filing Penalty: May trigger fines under IRC §6721

Incorrect TIN: Backup withholding 24% may apply

I-9 Violations: Civil fines $281–$2,789 per violation

Benefit Overpayment: Repayment collection and interest

Audit Risk: Increased documentation requests

Legal Challenge: Disputed entitlement litigation

eSignature pricing and feature snapshot for notice workflows

Comparison of common eSignature vendors and plan-level features relevant to serving notices and managing claims.

	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 free 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

Real-world examples of electronic notice use

Two concise case examples showing practical benefits from electronic notices and signed records.

Optica Ventures — COO

Optica Ventures relies on electronic notices to centralize claim data, improve consistency, and reduce manual entry across distributed teams.

Interface is simple and easy-to-use.
As a result, claim handlers complete notices faster, attachments are consistently included, and the organization preserves audit trails for oversight and regulatory compliance without increasing administrative headcount or delaying payments.

Martin Properties — Founder

Martin Properties processes temporary compensation notices online to finalize tenant and contractor claims, reducing the need for in-person signatures.

Processes documents online with full compliance.
This cut physical mailings and improved return rates; electronic timestamps and stored copies allowed quick responses to inquiries, easier reconciliation of payments, and clearer records for potential audits or legal review.

Frequently asked questions about the notice

Answers to frequent questions about completing, serving, and electronically submitting the Pennsylvania Notice of Temporary Compensation Payable.

Need help? Contact support

Who is responsible for completing the notice?
Employers or their authorized insurers/claims administrators typically complete the notice when temporary disability benefits are approved. In contested cases legal representatives may prepare notices; always ensure an authorized signatory signs and dates the form to avoid processing delays.
Is an electronic signature acceptable on the notice?
Yes, electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided the signer consents and the record is retained. Confirm state-specific submission rules and any Bureau e-filing requirements before e-submission.
Is notarization required for the notice?
Not generally required for routine notices to pay temporary compensation, but certain attachments or local agency procedures may request notarization. Verify with the Pennsylvania Bureau of Workers' Compensation or local counsel before adding notarial acknowledgments.
Which documents should I attach to the notice?
Include medical reports supporting temporary disability, wage statements used to calculate the weekly rate, and any authorization forms. Label files clearly and use PDF format where possible to preserve metadata and timestamps for audits and administrative review.
How long should copies of the notice be retained?
Retain signed notices and supporting documentation for at least the active claim period plus three years; retain medical records for six years under HIPAA (45 CFR §164.530(j)) and follow applicable state retention rules for longer periods.
How to update the notice if payments change?
Issue an amended Notice of Temporary Compensation Payable documenting new rates or revised dates. Serve amended copies to the claimant, insurer, and the Bureau as required, and keep prior versions in the file to preserve the payment history and audit trail.

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