Fill and Sign the Wc Claim Forms Department of Labor Ampampamp Industry

         DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION SUPPLEMENTAL 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 EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone INJURY INFORMATION Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN 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: Suspended, returned to work, no loss of wages Termination - - Modi�cation Recurred Speci�c loss MM DD YYYY Said employer shall pay employee compensation at the rate of $ per week beginning on - - MM DD YYYY 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, �nal receipt, or order of a Workers’ Compensation Judge, or the Workers’ Compensation Appeal Board. LIBC-337 REV 09-13 (Page 1)          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 pa rtial compensation rate (subject to the maximum bene�t) 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. Date of agreement - - MM DD YYYY 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 toll-free inside PA TTY: 800.362.4228 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991 *337*   Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-337 REV 09-13 (Page 2)