WCAIS Forms

ALERT: The Department is providing these forms for the sole purpose of using them within the WCAIS system and the workers' compensation business process.
Note: Faxing or attaching a document to an email is not a secure means of submitting data.
FORM NAME PRINT (P) INTERACTIVE (I)
LIBC-9 Workers' Compensation Medical Report Form P I
LIBC-10 Authorization for Alternative Delivery of Compensation Payments P I
LIBC-14 Instructions for Religious Exception Application P  
LIBC-14A Application for Religious Exception of Specified Employees from the Provisions of the Pennsylvania Workers' Compensation Act P I
LIBC-14B Employee's Affidavit and Waiver of Workers' Compensation Benefits and Statement of Religious Sect P I
LIBC-90 Electronic Data Interchange First Report of Injury P  
LIBC-91 Electronic Data Interchange Subsequent Report of Injury P  
LIBC-100 Workers’ Compensation and the Injured Worker P  
LIBC-100(ESP) Workers’ Compensation and the Injured Worker P  
LIBC-134 Dismemberment Chart P I
LIBC-134F Dismemberment Chart P I
LIBC-221i Self-Insured Employer's Initial Report of Accident and Illness Prevention Program P I
LIBC-230G Annual Report of Accident and Illness Prevention Program Status by Group Self-Insurance Funds P I
LIBC-231G Initial Report of Accident & Illness Prevention Program Status by New Group Self-Insurance Funds P I
LIBC-336 Agreement for Compensation for Disability Or Permanent Injury P I
LIBC-337 Supplemental Agreement for Compensation for Disability or Permanent Injury P I
LIBC-338 Agreement for Compensation for Death P I
LIBC-339 Supplemental Agreement for Compensation for Death P I
LIBC-340 Agreement to Stop Weekly Workers' Compensation Payments Final Receipt P I
LIBC-350 Group Self-Insurance Fund Member Annual Contribution Worksheet Form P I
LIBC-351 Expense Loss Cost Multiplier Worksheet for Group Self-Insurance Fund Using Rating Organization Loss Costs Multiplier Calculation Worksheet and Instructions P I
LIBC-352 Expense Loss Cost Multiplier Worksheet for Group Self-Insurance Fund Deviating From Rating Organization Loss Costs Multiplier Calculation Worksheet and Instructions P I
LIBC-362 Claim Petition for Workers' Compensation P I
LIBC-363 Fatal Claim Petition for Compensation by Dependents of Deceased Employees P I
LIBC 364B Defendant's Answer to Claim Petition Under Pennsylvania Occupational Disease Act P I
LIBC-365 Supplemental Information Addendum to Group Self-Insurance Fund Annual Report P I
LIBC-368 Supplemental Information Addendum to Application for Membership in a Group Workers' Compensation Fund P I
LIBC-369 Supplemental Information Addendum to Application as a Group Workers' Compensation Fund P I
LIBC-371 Supplemental Information Addendum to Annual Report of Runoff Group Self-Insurance Fund P I
LIBC-374 Defendant's Answer to Claim Petition Under PA Workers' Compensation Act P I
LIBC-375 Claim Petition for Additional Compensation From the Subsequent Injury Fund Pursuant to Section 306.1 of the Workers' Compensation Act P I
LIBC-376 Petition for Joinder of Additional Defendant P I
LIBC-377 Answer to Petition TO/FOR: P I
LIBC-378 Petition TO/FOR: (Check any that apply) P I
LIBC-380 Third Party Settlement Agreement P I
LIBC-387 Important Information about the Petition Filing and Hearing Process P  
LIBC-396 Occupational Disease Claim Petition Monthly Compensation for Disability Under Section 301(i) Only P I
LIBC-494A Statement of Wages (For Injuries Occurring On or Before June 23, 1996) P I
LIBC-494C Statement of Wages (For Injuries Occurring On or After June 24, 1996) P I
LIBC-495 Notice of Compensation Payable P I
LIBC-496 Notice of Workers' Compensation Denial P I
LIBC-497 Physicians Affidavit of Recovery P I
LIBC-499 Petition for Physical Examination or Expert Interview of Employee (Section 314) P I
LIBC-501 Notice of Temporary Compensation Payable P I
LIBC-502 Notice Stopping Temporary Compensation P I
LIBC-507 Application for Fee Review Pursuant to Section 306(F.1) P I
LIBC-509 Application for Executive Officer's Declaration P I
LIBC-513 Executive Officer's Declaration P I
LIBC-524 Defendant's Answer to Occupational Disease Claim Petition Section 301(i) Only P I
LIBC-550 Claim Petition for Benefits from the Uninsured Employer and the Uninsured Employers Guaranty Fund P I
LIBC-551 Notice of Claim Against Uninsured Employer P I
LIBC-601 Instructions for Completing Utilization Review Request P
LIBC-601 Utilization Review Request P I
LIBC-603 Petition for Review of Utilization Review Determination P I
LIBC-604 Utilization Review Determination Face Sheet P  
LIBC-606 Request for Hearing to Contest Fee Review Determination P I
LIBC-750 Employee Report of Wages P I
LIBC-751 Notification of Suspension or Modification Pursuant to 413(c) & (d) P I
LIBC-753 Notice of Request for an Informal Conference P I
LIBC-754 Informal Conference Agreement Form P I
LIBC-755 Compromise and Release Agreement by Stipulation Pursuant to Section 449 of the Workers' Compensation Act P I
LIBC-756 Employee's Report of Benefits for Offsets P I
LIBC-757 Notice of Ability to Return to Work P I
LIBC-760 Employee Verification of Employment, Self-Employment or Change in Physical Condition P I
LIBC-761 Notice of Workers' Compensation Benefit Offset P  
LIBC-764 Disability Status P I
LIBC-765 Impairment Rating Evaluation Appointment P I
LIBC-766 Request for Designation of a Physician to Perform an Impairment Rating Evaluation P I
LIBC-767 Impairment Rating Determination Face Sheet P I
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