LIBC-14B REV 7-02 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501
EMPLOYE'S AFFIDAVIT AND WAIVER OF WORKER'S COMPENSATION BENEFITS AND STATEMENT OF RELIGIOUS SECT
(To be filed with the ยง304.2 Application for Religious Exception)
EMPLOYE
EMPLOYER
STREET ADDRESS
STREET ADDRESS ZIP CODE
CITY/TOWN
STATE
CITY/TOWN
STATE
ZIP CODE
EMPLOYE SOCIAL SECURITY NUMBER
WAIVER OF WORKERS' COMPENSATION AND AFFIDAVIT I, _______________________________ , do hereby state and affirm that I am a member of ______________
EMPLOYE
____________________________________ . Its established tenets and/or teachings conscientiously oppose
RELIGIOUS SECT OR DIVISION
member acceptance of any public or private insurance benefits which make payments in the event of death, disability, old age, retirement, or towards the cost of medical bills and provision of services for medical bills (including the benefits of any insurance system established by the Federal Social Security Act), and I adhere to said tenets and/or teachings. I am, therefore, knowingly and voluntarily waiving my rights to any benefits under the Pennsylvania Workers' Compensation Act. Subscribed and affirmed to before me this _______ day of __________________ , 20 ____
SIGNATURE OF EMPLOYE (OR PARENT OR GUARDIAN IN CASE OF MINOR NOTARY PUBLIC (SEAL)
STATEMENT OF RELIGIOUS SECT I, ____________________________________ , hereby state and affirm that I am the religious leader of__________
RELIGIOUS SECT LEADER
________________________________ , and I verify that _____________________________ is a current
RELIGIOUS SECT ABOVE-NAMED EMPLOYE
member of this sect. I state and affirm that this religious sect has established tenets and/or teachings which oppose its members' acceptance of any public or private insurance benefits which make payments in the event of death, disability, old age, retirement, or toward the cost of medical bills and provision of services for medical bills (including the benefits of any insurance system established by the Federal Social Security Act). Furthermore, I state and affirm that it is the practice, and has been for ________ for members of this sect or division to make provision for
NUMBER OF YEARS
their dependent members which, in its judgment, is reasonable in view of their general level of living.
SIGNATURE OF RELIGIOUS SECT LEADER
TITLE
DATE