Fill and Sign the Us Department of Labor Office of Workers Compensation Form

\ \ \ \ Compensation Presently Payable Under: Notice of Compensation Payable Agreement Supplemental Agreement Award ANSWER TO PETITION FOR COMMUTATION EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - WCAIS CLAIM NUMBER - - DATE OF INJURY MM DD YYYY Name Address Address City/Town State ZIP County Telephone FEIN Name Address Address City/Town State ZIP County Telephone FEIN Contact NAIC code or Insurer code Insurer/TPA claim # First name Last name Date of birth Address Address City/Town State ZIP County Telephone EMPLOYEE EMPLOYER VS. INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) INJURY INFORMATION Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease Provide the following information if Employer has accepted liability for this injury: DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION TO YOUR HONORABLE JUDGE: In answer to the petition presented to your Honorable Judge by requesting commutation of future installments of compensation pa yable in the captioned case, (I)(we) submit for your consideration the following facts: LIBC-35 01-14 (Page 1) (I)(we) further submit for your consideration the following additional facts: F or the above reasons, (I)(we) request that your Honorable Judge the said petition for commutation in the captioned case. WHEREFORE, the respondent requests that the petition be dismissed or in the alternative disallowed. Notice: This answer must be �lled out as fully as possible. If not �ling electronically, the original must be sent to the of�ce of the Judge to whom the case is assigned. You must send a copy to all unrepresented parties, and to the attorney of record for all other parties which are represented by counsel. 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. Answers must be �led within 20 days of the assignment of the petition. Questions regarding the completion of this form may be directed to the Bureau of Workers’ Compensation Claims Information Services. PLEASE ENTER MY APPEARANCE FOR RESPONDENT: Attorney’s name PA Attorney ID number Firm name Date �led Address Address MM DD YYYY City/Town State ZIP Telephone Attorney’s signature Attorney’s name (typed/printed) Respondent’s signature Respondent’s name (typed/printed) 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 Informatio n Services Hearing Impaired Email Services toll-free inside P A: 800.482.2383 toll-free inside P A TTY: 800.362.4228 ra-li-bwc -helpline@pa.gov 717.772.3702 local & outside P A: 717.772.4447 local & outside P A TTY: 717.772.4991 *35* Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program LIBC-35 01-14 (Page 2)