Pennsylvania Workers' Compensation

Forms and Printing Instructions

To provide the best possible customer service available, the Pennsylvania Bureau of Workers' Compensation is providing its forms in soft copy.
  • Optical Character Recognition (OCR) forms should be reproduced by printers and software companies. Caution must be exercised when reproducing these files to ensure exact replication of the form(s).
     
  • Non-OCR forms do not require reproduction by printers or software companies. These forms may be downloaded from this page as needed, completed and submitted to the Bureau.
Separate printing instructions are provided below for the forms. These instructions are also available under each form name.
 
 
The matrix below shows the forms and formats (e.g. EPS, Corel Draw 8, Quark Xpress for Windows, Post Script, and PDF) currently available.
Click here to get Acrobat Reader You will need the Adobe Acrobat Reader to successfully view/print some information. This software is provided free of charge and you may download the latest version by clicking on the 'Get Acrobat Reader' button.
  • You can navigate by form number series.
  • Unnumbered forms are found in Misc.
Form Number/ Revision Date
Form Name
EPS
Formats
Other
Formats
OCR
#
of
sides
Duplex?
(Mandatory
when Yes)
Date
Accepted
Date
Required
LIBC-9
7-04
Medical Report Form
No special printing instructions required.
None
No
2
Yes
not applicable
not applicable
 
 
Form Number/ Revision Date
Form Name
EPS
Formats
Other
Formats
OCR
#
of
sides
Duplex?
(Mandatory
when Yes)
Date
Accepted
Date
Required
LIBC-10
6-04
Authorization for Alternative Delivery of Compensation Payments
No special printing instructions required.
None
No
1
No
1-1-2005
3-1-2005
LIBC-14
7-02
Instructions for Religious Exception Application
No special printing instructions required.
None
No
1
No
not applicable
not applicable
LIBC-14A
1-96
Section 304.2 Application for Religious Exception of Specified Employes from the Provisions of the Pennsylvania Workers' Compensation Act
Non-OCR Printing Instructions
None
PDF
May be filled out online and printed, or printed and filled out by hand.
No
2
No
not applicable
not applicable
LIBC-14B
7-02
Employe's Affidavit and Waiver of Workers' Compensation Benefits and Statement of Religious Sect
Non-OCR Printing Instructions
None
PDF
May be filled out online and printed, or printed and filled out by hand.
No
1
No
not applicable
not applicable
LIBC-134
7-10
Dismemberment Chart - Hand
No special printing instructions required.
None
No
1
No
not applicable
not applicable
LIBC-134F
7-10
Dismemberment Chart - Foot
No special printing instructions required.
None
No
1
No
not applicable
not applicable
 
 
Form Number/ Revision Date
Form Name
EPS
Formats
Other
Formats
OCR
#
of
sides
Duplex?
(Mandatory
when Yes)
Date
Accepted
Date
Required
LIBC-336
11-97
Agreement for Compensation
OCR Printing Instructions
None
Yes
1
No
8-1-1998
9-1-1998
LIBC-337
12-10
Supplemental Agreement for Compensation
OCR Printing Instructions
None
Yes
2
Yes
12-23-10
2-21-11
LIBC-338
12-97
Agreement for Compensation for Death
Non-OCR Printing Instructions
No
2
Yes
8-1-1998
9-1-1998
LIBC-339
12-97
Supplemental Agreement for Compensation for Death
Non-OCR Printing Instructions
No
2
Yes
8-1-1998
10-1-1998
LIBC-340
11-97
Agreement to Stop (Final Receipt)
OCR Printing Instructions
None
Yes
1
No
8-1-1998
9-1-1998
LIBC-362
6-08
Claim Petition
OCR Printing Instructions
None
Yes
2
Yes
6-27-08
6-27-08
LIBC-363
06-04
Fatal Claim Petition
Non-OCR Printing Instructions
None
No
2
Yes
1-1-2005
3-1-2005
LIBC-364B
12-97
Defendant's Answer to Claim Petition Under PA Occupational Disease Act
Non-OCR Printing Instructions
No
2
No
8-1-1998
10-1-1998
LIBC-374
08-11
Defendant's Answer to Claim Petition under PA Workers' Comp. Act
Non-OCR Printing Instructions
None
No
2
Yes
8-31-2011
not applicable
LIBC-375
2-10
Claim Petition for Additional Compensation From the Subsequent Injury Fund
Non-OCR Printing Instructions
None
No
2
Yes
3-31-2010
6-1-2010
LIBC-376
12-97
Petition for Joinder
Non-OCR Printing Instructions
None
No
2
Yes
8-1-1998
10-1-1998
LIBC-377
10-11
Answer to Petition To/For:
Non-OCR Printing Instructions
None
No
2
No
not applicable
not applicable
LIBC-378
10-11
Petition To/For:
- OCR Printing Instructions
- Important Notice
None
Yes
2
Yes
10-21-2011
12-22-2011
LIBC-380
3-06
Third Party Settlement Agreement
Non-OCR Printing Instructions
None
No
2
Yes
3-1-2006
1-3-2007
LIBC-384
04-04
Fatal...Covered by PA Occupational Disease Act
Non-OCR Printing Instructions
None
No
2
Yes
1-1-2005
3-1-2005
LIBC-386
02-05
Fatal...Resulting from Occupational Disease
Non-OCR Printing Instructions
None
No
2
Yes
8-1-2005
12-1-2005
LIBC-392A
9-08
Final Statement of Account of Compensation Paid
Non-OCR Printing Instructions
None
No
2
Yes
10-17-08
12-16-08
LIBC-396
10-09
Occupational Disease Claim Petition (under section 301(1) only)
Non-OCR Printing Instructions
None
No
2
Yes
12-21-2009
2-18-2010
 
 
Form Number/ Revision Date
Form Name
EPS
Formats
Other
Formats
OCR
#
of
sides
Duplex?
(Mandatory
when Yes)
Date
Accepted
Date
Required
LIBC-480
8-10
Subpoena
This form can be completed online and printed. No special printing instructions required.
None
No
1
No
8-31-2010
10-31-2010
LIBC-494A
12-97
Statement of Wages (for injuries occurring on or before June 23, 1996)
Non-OCR Printing Instructions
No
1
No
8-1-1998
10-1-1998
LIBC-494C
04-04
Statement of Wages (for injuries occurring on or after June 24, 1996)
OCR Printing Instructions
None
Yes
2
Yes
3-28-2005
8-1-2005
LIBC-495
09-03
Notice of Compensation Payable (NCP)
OCR Printing Instructions
None
PDF
Do not photocopy this form.
Yes
2
Yes
3-29-2004
6-1-2004
LIBC-496
03-11
Notice of Workers' Compensation Denial (NCD)
OCR Printing Instructions
None
Yes
2
Yes
4-20-11
6-20-11
LIBC-497
12-97
Physician's Affidavit of Recovery
Non-OCR Printing Instructions
No
1
No
8-1-1998
10-1-1998
LIBC-498
12-97
Commutation of Compensation
Non-OCR Printing Instructions
No
1
No
8-1-1998
10-1-1998
LIBC-499
12-97
Petition for Physical Examination
Non-OCR Printing Instructions
No
2
Yes
8-1-1998
10-1-1998
 
 
Form Number/ Revision Date
Form Name
EPS
Formats
Other
Formats
OCR
#
of
sides
Duplex?
(Mandatory
when Yes)
Date
Accepted
Date
Required
LIBC-500
5-09
Insurance Posting Form
Remember: It is important to tell your employer about your injury
None
No
1
No
6-1-2004
8-1-2004
LIBC-501
3-07
Notice of Temporary Compensation
OCR Printing Instructions
None
Yes
1
No
7-2-2007
8-28-2007
LIBC-502
12-97
Notice Stopping Temporary Compensation
Non-OCR Printing Instructions
No
1
No
8-1-1998
9-1-1998
LIBC-507
7-08
Application for Fee Review Pursuant to Section 306 (F.1)
None
Yes
2
Yes
12-1-2008
2-1-2009
LIBC-510
8-02
Employer's Application to Elect Domestic Employees to Come Within Provisions of the Workers' Compensation Act: Section 321
Non-OCR Printing Instructions
None
PDF
May be filled out online and printed, or printed and filled out by hand.
No
1
No
not applicable
not applicable
LIBC-550
6-11
Claim Petition for Benefits from the Uninsured Employer and the Uninsured Employers Guaranty Fund
None
No
2
Yes
6-30-11
8-30-11
LIBC-551
6-11
Notice of Claim Against Uninsured Employer
None
No
2
Yes
6-30-11
8-30-11
 
 
Form Number/ Revision Date
Form Name
EPS
Formats
Other
Formats
OCR
#
of
sides
Duplex?
(Mandatory
when Yes)
Date
Accepted
Date
Required
LIBC-601
04-12
Utilization Review Request (Instruction Sheet and Form)
OCR Printing Instructions
None
PDF

Do not photocopy this form
Yes
Instruction Sheet=1
 
UR Request=2
Instruction Sheet=No
 
UR Request=Yes
4-1-2012 Update to instructions only; no need to retest form.
4-1-2012
LIBC-603
07-11
Petition to Review Utilization Review Determination
Non-OCR Printing Instructions
None
No
2
Yes
7-1-2011
10-1-2011
LIBC-606
06-11
Request for Hearing to Contest Fee Review Determination
Non-OCR Printing Instructions
None
No
2
Yes
7-6-2011
Not applicable
LIBC-662
07-07
Application for Supersedeas Fund Reimbursement
Non-OCR Printing Instructions
None
No
2
Yes
8-31-2007
10-30-2007
 
 
Form Number/ Revision Date
Form Name
EPS
Formats
Other
Formats
OCR
#
of
sides
Duplex?
(Mandatory
when Yes)
Date
Accepted
Date
Required
LIBC-749
2-11
Death Claim Supplement to Compromise and Release Agreement
Non-OCR Printing Instructions
None
No
2
No
1-1-2011
2-1-2011
LIBC-750
12-97
Employee Report of Wages and Physical Condition
Non-OCR Printing Instructions
No
2
No
8-1-1998
10-1-1998
LIBC-751
5-06
Notice of Suspension or Modification
OCR Printing Instructions
None
Yes
2
Yes
10-6-2006
12-7-2006
LIBC-753
12-97
Notice of Request for Informal Conference
Non-OCR Printing Instructions
No
2
No
8-1-1998
10-1-1998
LIBC-754
12-97
Informal Conference Agreement Form
Non-OCR Printing Instructions
No
2
No
8-1-1998
10-1-1998
LIBC-755
1-11 
Compromise and Release Agreement
Non-OCR Printing Instructions
None
No
4
No

1-1-2011

2-1-2011
LIBC-756
12-97
Employee's Report of Benefits for Offsets
Non-OCR Printing Instructions
No
2
No
8-1-1998
10-1-1998
LIBC-757
5-04
Notice of Ability to Return to Work
Non-OCR Printing Instructions
None
No
1
No

1-1-2005

3-1-2005
LIBC-758
2-11
Notice to Employee
Non-OCR Printing Instructions
Note: This form is to be attached to LIBC-378 ("Petition To:" form).
None
No
1
No
4-6-2011
6-6-2011
LIBC-760
3-07
Employee Verification of Employment, Self-Employment
Non-OCR Printing Instructions
None
No
2
No
4-2-07
6-1-07
LIBC-761
8-01
Notice of Workers' Compensation Benefit Offset
Non-OCR Printing Instructions
No
2
Yes

12-7-01

2-1-02
LIBC-762
12-97
Notice of Suspension-Failure to Return Form LIBC-760
Non-OCR Printing Instructions
No
2
Yes
8-1-1998
10-1-1998
LIBC-763
12-97
Notice of Reinstatement of Workers' Compensation Benefits
Non-OCR Printing Instructions
No
1
No
8-1-1998
10-1-1998
LIBC-764
12-97
Notice of Change of Workers' Compensation Disability Status
Non-OCR Printing Instructions
No
2
Yes
5-1-1998
5-1-1998
LIBC-765
12-97
Impairment Rating Evaluation Appointment
Non-OCR Printing Instructions
No
2
Yes
5-1-1998
5-1-1998
LIBC-766
3-08
Request for Designation of a Physician to Perform an Impairment Rating Evaluation
Non-OCR Printing Instructions
None
No
2
Yes
5-1-2008
7-1-2008
LIBC-767
5-06
Impairment Rating Determination Face Sheet
Non-OCR Printing Instructions
None
No
2
Yes
5-17-2006
1-1-2007
 
 
Form Name
EPS
Formats
Other
Formats
#
of
sides
Duplex?
(Mandatory
when Yes)
Notice: Medical Treatment for Your Work Injury or Occupational Illness
No special printing instructions required.
None
2
Yes
 
If you have questions regarding the above forms or if you need a paper sample of what the final product must look like, you are encouraged to contact the Bureau's Helpline at:
 
Within Pennsylvania
1-800-482-2383
Outside Pennsylvania
717-772-4447
 
You may also direct questions regarding the above forms to: ra-li-bwc-helpline@pa.gov
 
Please note that all e-mail questions must: concern only the above forms; be in 25 words or less; and must include a daytime telephone number.
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