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WC Claim Forms Department of Labor and Industry

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Supplemental Agreement for Compensation for Disability or Permanent Injury

Department of Labor & Industry
Bureau of Workers’ Compensation

Employee Social Security Number or WC ID Number

Date of Injury

WCAIS Claim Number

EMPLOYEE

First name

Last name

Date of birth

Address

Address

City/Town, State, ZIP

County

Telephone

EMPLOYER

Name

Address

Address

City/Town, State, ZIP

County

Telephone / FEIN

INJURY INFORMATION

Part of body injured

Nature of injury

Accident/injury description narrative

Check if occupational disease

INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)

Name

Address

Address

City/Town, State, ZIP

County

Telephone / FEIN

Contact

NAIC code or Insurer code

Insurer/TPA claim #

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. Weekly wages must be completed in accordance with the Pennsylvania Workers’ Compensation Act.

Whereas, the undersigned employer and employee hereby agree that the status of the employee’s disability changed on

as follows:

Said employer shall pay employee compensation at the rate of $ per week beginning on

Compensation is payable for weeks days; or, if the future period of disability is uncertain, then to continue at said-rate until further changed by supplemental agreement, final receipt, or order of a Workers’ Compensation Judge, or the Workers’ Compensation Appeal Board.

The employee’s new partial compensation is based on the employee’s present weekly earnings and is calculated as follows:

Calculation: Average weekly wage at time of injury

Minus: Present weekly earnings

Subtotal

x 2/3= New partial compensation rate (subject to the maximum benefit)

Further matters agreed upon (list any previously unreported periods of compensation and/or actions in chronological order, as well as additional information):

We, the undersigned, agree upon the matters represented herein by the above named employee and the above named employer.

Employee’s signature

Date of agreement

Claims Representative’s signature

Claims Representative’s name (typed/printed)

Telephone

Any individual filing 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 Services
717.772.3702
Claims Information Services
toll-free inside PA: 800.482.2383
local & outside PA: 717.772.4447
Hearing Impaired
toll-free inside PA TTY: 800.362.4228
local & outside PA TTY: 717.772.4991
Email
ra-li-bwc-helpline@pa.gov

Auxiliary aids and services are available upon request to individuals with disabilities.

Equal Opportunity Employer/Program

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What the WC Claim Forms Department of Labor and Industry Covers

WC Claim Forms Department of Labor and Industry refers to the set of workers' compensation claim documents used to report workplace injuries, establish a claim file, and begin medical and wage-loss benefit processing with the employer, insurer, and state agency. These forms record claimant and employer data, incident details, medical treatment, and wage information used for eligibility determinations, claim numbers, and administrative hearings. Many states accept electronic submissions and attachments, but procedural differences and evidence requirements vary by jurisdiction and employer insurer practices.

Why accurate WC claim forms matter

Properly completed WC claim forms create the official record that triggers medical care, wage-loss evaluations, and coverage determinations; accurate forms reduce processing delays, limit disputes, and support timely payments while helping employers meet statutory notice and reporting obligations.

Why accurate WC claim forms matter

Primary users and contributors

Coordination among these parties ensures the claim moves through intake, adjudication, and benefit payment efficiently.

  • Injured workers: Provide personal details, injury description, date of injury, and treatment history to start a claim.
  • Employers / HR teams: Complete employer-reporting sections, confirm payroll and job duties, and forward documents to insurer.
  • Medical providers: Submit treatment reports, diagnostic findings, and return-to-work notes tied to the claim file.

Step-by-step: filing a WC claim

Follow these core steps to file a workers' compensation claim with the employer, insurer, and state agency.

  • 01
    Seek medical care: Obtain initial treatment and medical documentation immediately after the injury.
  • 02
    Notify employer: Tell your employer about the injury according to company policy and state law.
  • 03
    Complete claim form: Fill claimant sections and collect employer/medical inputs before submission.
  • 04
    Submit to insurer/DOLI: Send completed forms and medical records to the employer, insurer, and state office as required.

Who receives the completed form and what happens next

After submission the document follows a typical routing and processing workflow to establish the official claim record and begin benefits review.

  • Employer: Receives initial notice and completes its employer-reporting portion for insurer filing.
  • Insurer: Opens a claim file, assigns an adjuster, and requests medical records if needed.
  • State agency: May receive a copy or notice and will track claims for compliance and statistics.
  • Medical providers: Submit treatment reports and bills linked to the claim number for payment consideration.

Typical eSubmission settings and routing

Configure these workflow elements when setting up online submission or eSignature routing for WC claim forms.

Field Configuration
Authentication method Email link, SMS code, or stronger ID verification
Attachments required Medical records, incident photo, employer statement
Routing order Claimant → Employer → Insurer → State agency
Notification triggers On-sign, on-complete, and exception alerts to adjuster

Technical considerations for eSubmission and eSignatures

Confirm platform capabilities to meet identity, format, and retention needs before accepting electronic claim forms.

  • File formats: PDF, DOCX, and image attachments supported
  • Identity checks: Email, SMS, or advanced KBA options
  • Integrations: Connects with HR and claims systems

Core components of a professional WC claim submission

A complete WC claim package contains claimant data, employer details, incident facts, medical documentation, wage history, and official signatures to support administration and adjudication.

Claimant Details

Full legal name, date of birth, SSN/TIN, contact information, and job title — used for identity verification, benefit calculations, and correspondence throughout the claim lifecycle.

Employer Report

Employer legal name, address, policy number, payroll and job description; this section anchors the claim to the correct policy and establishes employment status and wage bases.

Incident Facts

Clear statement of injury mechanics, location, witnesses, and immediate actions taken; concise incident narratives reduce follow-up requests and clarify compensable events.

Medical Records

Initial treatment notes, diagnoses, procedures, and follow-up plans from treating providers; these documents substantiate medical necessity and support temporary or permanent impairment assessments.

Earnings Information

Recent wage statements or payroll records used to calculate average weekly wage, benefit rates, and potential wage-loss benefits during recovery periods.

Signatures and Dates

Signed claimant and employer attestations, plus provider signatures where required; signatures establish intent and authenticate the factual record for adjudicators.

Required form fields at a glance

Claimant Name: Full legal name
Date of Injury: MM/DD/YYYY
Employer Details: Name and policy
Injury Description: Brief incident text
Medical Provider: Provider name
Signature: Signed and dated

Consequences of incomplete or incorrect forms

Delayed Benefits: Late or missing data delays medical and wage payments
Claim Denial: Insufficient evidence may lead to denial
Investigation: Inconsistent statements prompt further review
Financial Exposure: Employers may face penalties for late reporting
Regulatory Action: State agencies may assess fines
Fraud Risk: False statements can lead to prosecution

Common errors that slow claims

  • Incomplete incident descriptions that omit date, time, or location often require supplemental statements and delay adjudication while investigators gather facts.
  • Mismatched claimant identifiers—name, SSN, or date of birth—cause identity verification failures and can route the file to manual review.
  • Missing or unsigned employer sections and absent medical reports are frequent reasons insurers request re-submission and pause benefit payments.
  • Submitting scanned documents with illegible text, truncated pages, or missing attachments increases processing time and can trigger claims being returned for correction.

Timing considerations and typical submission windows

Specific deadlines differ by state; follow employer and state agency rules and act promptly to preserve benefits and appeal rights.

Initial Worker Notice:

Provide notice to employer as soon as practicable

Employer Reporting:

Employer must report to insurer per state timeframe (varies)

Medical Bill Submission:

Submit bills promptly to avoid payment denials

Appeal Deadlines:

Adverse decisions carry short appeal windows

Document Corrections:

Correct errors immediately upon notice to minimize delays

Key milestones from injury to resolution

A typical claim follows these sequential stages from event through final determination and potential appeals.

01

Injury Occurs

Incident happens and immediate care is sought.

02

Employer Notice

Worker notifies employer and employer documents the event.

03

Claim Filed

Claimant completes forms; employer/insurer opens file.

04

Decision / Appeal

Insurer or agency issues determination; appeal may follow.

Comparing eSignature vendors for WC claim form workflows

Platform pricing and capabilities differ; choose a vendor that supports required authentication, audit trails, and integrations with claims or HR systems.

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

Frequently asked questions about WC claim form completion

Answers to frequently asked questions about filing, correcting, and validating workers' compensation claim forms and electronic signatures.


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