Fill and Sign the Workers Compensation Pa Dli Pagov Form

EMPLOYER \ \ \ department of labor & industry bureau of workers’ compensation NOTIcE Of AbILITY TO RETURN TO wORk 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 NOTICE - - MM DD YYYY DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY 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 # Section 306(b)(3) of the Pennsylvania Workers’ Compensation Act requires insurers to notify the employee when they receive medical evidence indicating the ability to return to work in some capacity. Receipt of medical evidence indicates your present physical condition or change of condition is: Attached are all documents supporting these allegations. YOU SHOULD ALSO kNOw You have an obligation to look for available employment. Proof of available employment may jeopardize your right to receive ongoing bene�ts. You have the right to consult with an attorney in order to obtain evidence to c\ hallenge the insurer’s contributions. 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). Auxiliary aids and services are available upon request to individuals wi\ th disabilities. 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 *757* Equal Opportunity Employer/Program LIBC-757 REV 09-13