Bureau of Workers' Compensation

LIBC-14

Instructions for Religious Exception Application

This application is to be used to request an "employe religious exception" from coverage under the Pennsylvania Workers’ Compensation Act pursuant to §304.2 of the Act. All questions must be answered.
 
An executed and notarized copy of Form LIBC-14B, Employe’s Affidavit and Waiver of Workers’ Compensation Benefits and Statement of Religious Sect must be attached to this application for each employe for whom exception is sought. It is necessary that the Religious Sect Leader complete and sign a portion of the form. In the event that the employe has previously been excepted from coverage, a copy of Form LIBC-14C, Certification of Religious Exception, may be attached instead of Form LIBC-14B provided the employe continues to be a member of the same religious sect and continues to adhere to its teachings and tenets.
 
All employes requesting an exception who are members of the same religious sect or division may be included on one application. If additional space is required, indicate at the bottom of Question 7 and attach additional listing.
 
A separate application is required for each religious sect or division thereof under which employe(s) are requesting an exception to the Pennsylvania Workers’ Compensation Act.
 
Notification must be supplied to the Bureau of Workers’ Compensation if any of the employes who are granted such an exception cease to be qualified for that exception.
 
PA Department of Labor & Industry
Bureau of Workers’ Compensation
1171 South Cameron Street, Room 103
Harrisburg, PA 17104-2501
 
LIBC-14 REV 7-02
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