Free LIBC-374 - Pennsylvania

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 TTY 800-362-4228

DEFENDANT'S ANSWER TO CLAIM PETITION UNDER PENNSYLVANIA WORKERS' COMPENSATION ACT
Employer

Social Security Number: Date of Injury
MM

/
DD

/
YYYY (IF KNOWN)

PA BWC Claim Number:

Employee
First Name _______________________________ Street 1 Last Name _________________________________________

Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County _________________________________ Telephone (______) _______-__________________ __________ _________-_______

___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County __________ Telephone __________-_______

___________________________________________ (______) _______-_______________

FEIN ______________________________

VS.

Insurer or Third Party Administrator (if self-insured)
Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-___________________ County __________________________________ Claim Number __________________________________ __________ Bureau Code __________-_______

______________________________

FEIN ______________________________

TO YOUR HONORABLE JUDGE: In answer to the captioned claim, the Defendant respectfully pleads as follows: (Answers must be identified by numerical order in direct response to corresponding numbered allegations on claim petition.) ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ NOTICE: This answer should be clearly completed (preferably typed) and original mailed directly to the office of the Judge to whom the case is assigned. Answers must be filed within 20 days. Every fact alleged in the claim petition not specifically denied by this answer shall be deemed to be admitted. (OVER)
LIBC-374 REV 5-04 (Page 1)

As a matter of further defense, the Defendant states the following: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ __________________________________________________________________________________________________________ WHEREFORE, the Defendant requests that the claim petition be dismissed or in the alternative disallowed. PLEASE ENTER MY APPEARANCE FOR DEFENDANT: Attorney
Last Name _______________________________________ First Name _____________________________ Firm Name Last Name ___________________________________________

Defendant
First Name __________________________ Signature

____________________________________________________________________

___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-_________________ __________ __________-_______ PA Attorney ID Number ______________________________

Date: _________/____________/_____________
MM DD YYYY

Attorney
Signature

____________________________________________________________________

Date: _________/____________/_____________
MM DD YYYY

Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program
LIBC-374 REV 5-04 (Page 2)