Fill and Sign the Temporary Workers Form

                                                                                                                                                                                                                                                            Biweekly Other (Specify):            Name of Claims Representative            EMPLOYEE SOCIAL SECURITY NUMBER COMMONWEALTH OF PENNSYLVANIADEPARTMENT OF LABOR AND INDUSTRYBUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103HARRISBURG PA 17104-2501(TOLL FREE) 800-482-2383 NOTICE OF TEMPORARY 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 County 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 ofCompensation 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 $ . MONTH DAY YEAR MONTH DAY YEAR 2. Payments begin on Ninety day period ends on 3. Payments will hereafter be made: Weekly until payments cease or the ninety-day maximum period for temporary compensation expires. 4. Remarks: 501 1197-1 Signature of Claims Representative Any individual filing misleading or incomplete information knowingly and with intent to Phone Number defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Actand may also be subject to criminal and civil penalties through Pennsylvania Act 165. LIBC-501 REV 11-97