Fill and Sign the Work Comp Form Notice of Benefit Reinstatement

\ \ \ \ \ department of labor & industry bureau of WorKers’ Compensation NOTICE OF REINSTATEMENT OF WORKERS’ COMPENSATION BENEFITS EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone DATE OF THIS NOTICE: - - MM DD YYYY DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY 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 NAIC code or Insurer code Insurer/TPA claim # ATTORNEY FOR EMPLOYEE (if known) ATTORNEY FOR INSURER/EMPLOYER (if known) Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number Name Signature Address Address City/Town State ZIP Telephone FEIN A COPY OF THIS FORM AND ATTACHMENTS ARE TO BE PROVIDED TO THE EMPLOYEE A\ ND THE EMPLOYEE’S ATTORNEY (IF KNOWN). (OVER) LIBC-763 REV 09-13 (Page 1) - - You are hereby noti�ed that your workers’ compensation bene�ts are reinstated as of , the date MM DD YYYY your Employee Veri�cation of Employment, Self-Employment or Change in Physical Condition (LIBC-760) was received, which indicated NO changes of employment, self-employment or change in physical condition. - OR- - - You are hereby noti�ed that your workers’ compensation bene�ts are resumed as of , the date MM DD YYYY your completed LIBC-760 form was received. A bene�t offset will occur as indicated on the attached Notice of Workers’ Compensation Bene�t Offset (LIBC-761). 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 Info rmation Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 r a-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991 *763* Auxiliary aids and services are available upon request to individuals wi\ th disabilities. Equal Opportunity Employer/Program LIBC-763 REV 09-13 (Page 2)