Free LIBC-496 REV 6-06.cdr - Pennsylvania


File Size: 26.3 kB
Pages: 2
Date: February 16, 2007
File Format: PDF
State: Pennsylvania
Category: Workers Compensation
Author: Commonwealth of PA
Word Count: 801 Words, 4,900 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dli.state.pa.us/landi/lib/landi/bwcLIBC-496.pdf

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EMPLOYEE SOCIAL SECURITY NUMBER COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET ROOM 103 , HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 DATE OF NOTICE MONTH

NOTICE OF WORKERS' COMPENSATION DENIAL

DATE OF INJURY

DAY YEAR

-

PA BWC CLAIM NUMBER (IF KNOWN) MONTH DAY YEAR

EMPLOYEE
First Name Last Name Address Address City/T own County Telephone ( ) State Zip

EMPLOYER
Name Address Address City/T own County Telephone ( ) FEIN State Zip

INSURER or THIRD PARTY ADMINISTRATOR (if self insured)
Name Address Address City/T own Telephone ( County ) State Zip

ALLEGED INJURY INFORMATION
Body Part(s) affected Type of Injury Description of Injury

Bureau Code

Check if Occupational Disease

Claim #

FEIN

NOTICE: The employer has decided to deny you workers' compensation benefits. You have the right to contest this denial by timely filing a petition with the Bureau. See the reverse side of this Denial Form for more information. This Denial shall be sent to the employee or dependent and filed with the Bureau no later than 21 days after notice or knowledge to the employer of the employee's disability or death. Date employer received notice or knew of alleged injury or date of employee's claimed disability: This date must be completed. The employer/insurer declines to pay workers' compensation benefits to claimant because: 1. 2. 3. 4. 5. 6. The employee did not suffer a work-related injury. The definition of injury also includes aggravation of a pre-existing condition, or disease contracted as a result of employment. The injury was not within the scope of employment. The employee was not employed by the defendant. Although an injury took place, the employee is not disabled as a result of this injury within the meaning of the Workers' Compensation Act. The employee did not give notice of his/her injury or disease to the employer within 120 days within the meaning of Sections 311313 of the Workers' Compensation Act. Other good cause. Please explain fully in the space below. Failure to obtain medical confirmation of the injury will not be considered good cause to deny benefits if caused by dilatory conduct of insurance carrier or employer.

MONTH DAY

YEAR

If it is alleged that physicians' reports were requested and not received, please give the date(s) they were requested. Attach a copy of request(s) for release(s). List dates:

Name of Claims Representative

Signature of Claims Representative

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. LIBC-496 REV 7-06 (Page 1)

496 0706

-over-

EMPLOYEE'S RIGHTS TO CONTEST DENIAL OF WORKERS' COMPENSATION BENEFITS You have the right to contest this denial of your claim for workers' compensation benefits. Your petition will be heard by a Workers' Compensation Judge. You and your employer will have the opportunity to testify and provide medical evidence with respect to your claim. Both you and your employer will have the right to bring witnesses. You may retain an attorney to represent you in this proceeding although representation by an attorney is not required by law. Because of the legal complications that can arise in occupational disease and workers' compensation cases, you may want to consider legal advice. If you do not know how to contact an attorney, please contact your local Bar Association Lawyer Referral Service. The procedure for filing a petition is as follows: 1. At your request, a petition will be mailed to you. You and/or your attorney need to fill this out and return it to the Bureau with appropriate copies. One copy should be sent by you to your employer. 2. A petition for an injury must be filed within three years of the date of injury. For occupational disease claims, disability or death must occur within 300 weeks from last exposure. A petition must be filed no later than three years from that date. Failure to file a petition within these rules may result in a loss of your claim. 3. You must give notice of your work-related injury or disease to your employer within 120 days of the date you knew (or should have known) that you were injured or had contracted a work-related disease. 4. When your petition is received by the Bureau of Workers' Compensation, it will be assigned to a Judge for hearing. You will be notified of your hearing date. All parties are requested to be fully prepared prior to the first hearing. If you need petition forms or have questions, please contact the Bureau of Workers' Compensation: TOLL FREE: 800-482-2383

Auxiliary aids and services are available upon request to individuals with disabilities Equal Opportunity Employer/Program

LIBC-496 REV 7-06 (Page 2)