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EMPLOYEE EMPLOYER INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) INJURY INFORMATION NOTICE: Agreement should be clearly completed, (preferably typed) and uploaded in accordance with the provisions of the EDI Implementation Guide. A copy must be sent to the employee. Wage information must be completed in accordance with the Pennsylvania Workers’ Compensation Act, and sent to the employee. DATE DISABILITY BEGAN The employer shall pay the employee compensation at a rate of $ per week on an average weekly wage of $ beginning . Date �rst check mailed . If the date exceeds the 21-Day Rule, check this box And explain under “further matters agreed upon” on reverse. Payment of medical and hospital expenses are subject to the limits of time and amount provided by the Pennsylvania Workers’ Compensation Act and subject to modi�cation or termination with the Act. Compensation payable for weeks days for loss or loss of use of under Section 306(c). Compensation payable for weeks days for healing period for loss or loss of use of under Section 306(c). Compensation payable for weeks days for dis�gurement under Section 306(c). Please describe the dis�gurement. LIBC-336 REV 04-18 (Page 1) AGREEMENT FOR COMPENSATION FOR DISABILITY OR PERMANENT INJURY EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - - - DATE OF INJURY WCAIS CLAIM NUMBER MM DD YYYY Name AddressAddress City/Town State ZIP County Telephone FEIN First name Last nameDate of birthAddressAddress City/Town State ZIP County Telephone Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease - - MM DD YYYY - - MM DD YYYY Name AddressAddress City/Town State ZIP County Telephone FEINContactNAIC code or Insurer code Insurer/TPA claim # DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION Further matters agreed upon: LIBC-336 REV 04-18 (Page 2)Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program We, the undersigned, agree upon the matters represented herein by the above named employee and the above named employer. Employee’s signature Claims Representative’s signature Claims Representative’s name (typed/printed) Telephone 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 PA Relay 7-1-1 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 *336* - - Date of agreement MM DD YYYY