Pennsylvania Workers’ Compensation Act

Appendices

Appendix A
Additional Provisions of the Act

The following provisions were enacted as part of Act 57 of 1996:

Section 30

For the purpose of initial filing only, notwithstanding any other provisions of this act, the following shall apply:
(1) No later than 45 days after the effective date of this section, the Insurance Commissioner shall appoint an independent actuary to provide an estimate of the total change in workers’ compensation loss-cost resulting from implementation of this act and resulting from implementation of the act of July 2, 1993 (P.L.190, No.44), entitled "An act amending the act of June 2, 1915 (P.L.736, No.338), entitled, as reenacted and amended, ‘An act defining the liability of an employer to pay damages for injuries received by an employe in the course of employment; establishing an elective schedule of compensation; providing procedure for the determination of liability and compensation thereunder; and prescribing penalties,’ adding and amending certain definitions; redesignating referees as workers’ compensation judges; further providing for contractors, for insurance and self-insurance, for compensation and for payments for medical services; providing for coordinated care organizations; further providing for procedures for the payment of compensation and for medical services and for procedures of the department, referees and the board; adding provisions relating to insurance, self-insurance pooling, self-insurance guaranty fund, health and safety and the prevention of insurance fraud; further providing for certain penalties; making repeals; and making editorial changes," and an estimate of any other change attributable to data not considered in any previous loss-cost filing. The fee for this independent actuary shall be borne by the Workmen’s Compensation Administration Fund. In developing the estimate, the independent actuary shall consider all of the following:
 
(i) The most recent policy year unit statistical and financial loss-cost data available after policy year 1993. Notwithstanding any other provision of this section, for purposes of this subparagraph, the Coal Mine Compensation Rating Bureau shall submit the most recent accident or calendar year statistical and financial loss-cost data available after accident or calendar year 1993.
 
(ii) The standards set forth in section 704 of the act, as applicable.
 
(iii) Any other relevant factors within and outside this Commonwealth in accordance with sound actuarial principles.
 
(2) No later than 15 days after the effective date of this section, each insurer, including the State Workmen’s Insurance Fund, shall file loss data as required under paragraph (1) with its rating organization. For failure to comply, the commissioner shall impose an administrative penalty of $1,000 for every day that this data is not provided in accordance with this paragraph.
 
(3) No later than 45 days after the effective date of this section, each rating organization shall provide to the independent actuary, the commissioner and the small business advocate aggregate loss-cost data equal to or greater than 75% of the total data expected from all insurers, including the State Workmen’s Insurance Fund. For failure to comply by any rating organization, the commissioner shall impose an administrative penalty of $1,000 for every day that the data is not provided in accordance with this paragraph unless caused by the late reporting of any insurer. The commissioner shall impose an administrative fine of $1,000 upon any insurer whose late reporting of data causes such a delay, for every day beyond the required time frame of this paragraph until the aggregate loss-cost data is reported. This fine is in addition to any fine imposed for the late reporting of data to the rating organization under paragraph (2).
 
(4) No later than 95 days after the effective date of this section, the independent actuary shall complete and send the estimate of total loss-cost change to the commissioner, each rating organization, the Small Business Advocate, the President pro tempore of the Senate and the Speaker of the House of Representatives. The commissioner shall make the estimate available for public inspection.
 
(5) No later than 25 days after the independent actuary completes and sends the report referred to in paragraph (4), each rating organization shall, pursuant to section 709(c) of the act, file new loss-cost changes which reflect the estimate of the sum total of loss-cost data compiled under this section. For failure to comply, the commissioner shall impose an administrative penalty of $1,000 for every day that the loss-cost filing is not provided in accordance with this paragraph.
 
(6) The commissioner shall give full consideration to the independent actuary’s estimate from paragraph (4) in approving, disapproving or modifying the filing made under paragraph (5), pursuant to Article VII of the act. No later than 30 days after the approval of the filing, each new and renewal policy for workers’ compensation shall reflect the new loss-cost filing of its rating organization.
 
(7) The commissioner shall appoint and retain an independent actuary in accordance with this section until the independent actuary has prepared and sent the estimate as required by paragraph (4). The commissioner may appoint and retain an independent actuary after the estimate required by paragraph (4) has been completed and sent.
 
(8) For the purpose of this section, an "independent actuary" means a member in good standing of the Casualty Actuarial Society or a member in good standing of the American Academy of Actuaries, who has been approved as qualified for signing casualty loss reserve opinions by the Casualty Practice Council of the American Academy of Actuaries and who is not an employee of the Commonwealth.

Section 31

In a provision of the act not affected by this act, a reference to the word "referee" shall be deemed a reference to the phrase "workers’ compensation judge."

Section 31.1

Any reference in a statute to the Workmen’s Compensation Appeal Board shall be deemed a reference to the Workers’ Compensation Appeal Board.

Section 31.2

Regulations of the Department of Health promulgated under section 306(f.2)(7) of the act shall be deemed regulations of the Department of Labor and Industry. The Legislative Reference Bureau shall recodify the regulations.

Section 32

The provisions of this act are severable. If any provision of this act or its application to any person or circumstance is held invalid, the invalidity shall not affect other provisions or applications of this act which can be given effect without the invalid provision or application.

Section 32.1

(a) The amendment or addition of sections 204(a), 306(a.2) and (b)(2) and 309 of the act shall apply only to claims for injuries which are suffered on or after the effective date of this section.
 
(b) The addition of section 1402(a)(1) of the act shall not apply to the individual acting as director of adjudication on the effective date of this section.

Section 32.2

The act of June 2, 1915 (P.L.762, No.340), referred to as the State Workmen’s Insurance Fund Law, is repealed.

Section 33

This act shall take effect as follows:
(1) The following provisions shall take effect immediately:
 
(i) The addition of section 306(a.2) of the act.

(ii) The addition of Article XV of the act.

(iii) Section 32.1 of this act.

(iv) Section 32.2 of this act.

(v) This section.
 
(2) The remainder of this act shall take effect in 60 days.
[Editor’s Note: Act 57 was approved June 24, 1996.]
 
The following provisions were enacted as part of Act 44 of 1993:

Section 23

The Commonwealth, its political subdivisions, their officials and employees acting within the scope of their duties shall enjoy and benefit from sovereign and official immunity from claims of subrogation or reimbursement from a claimant’s tort recovery with respect to workers’ compensation benefits.

Section 25

(a) The following act and parts of acts are repealed to the extent specified:
 
Section 654 of the act of May 17, 1921 (P.L. 682, No. 284), known as The Insurance Company Law of 1921, except with regard to insurance as to liability under the Longshore and Harbor Workers’ Compensation Act (44 Stat. 1424, 23 U.S.C. §901 et seq.).
 
75 Pa.C.S. §§ 1735 and 1737, absolutely.
 
(b) The provisions of 75 Pa.C.S. §§ 1720 and 1722 are repealed insofar as they relate to workers’ compensation payments or other benefits under the Workers’ Compensation Act.
 
(c) All other acts and parts of acts are repealed insofar as they are inconsistent with this act.

Section 26

No changes in indemnity compensation payable by this act shall affect payments of indemnity compensation for injuries sustained prior to the effective date of this section.
 
[Editor’s Note: Act 44 was approved July 2, 1993.]
 
The following provisions were enacted as part of Act 1 of 1995:

Section 3

This act shall apply as follows:
(1) Except as provided in paragraph (2), the amendment or addition of sections 105.4, 105.5, 105.6 and 306(c)(8) of the act shall apply to claims filed on or after the effective date of this act.
 
(2) The amendment or addition of sections 105.5 and 306(c)(8)(I), (II) and (IV) shall apply retroactively to all claims existing as of the effective date of this act for which compensation has not been paid or awarded.

Section 4

This act shall take effect immediately.
 
[Editor’s Note: Act 1 was approved February 22, 1995.]
 

Appendix B
Accidents Reported to Department of Labor and Industry

Act of 1913, P.L. 843, Amended 1937,
P.L. 56 (43 P.S.§ 12-16)
AN ACT
Requiring employers to make report to the Department of Labor and Industry of accidents to employes, and prescribing a penalty, for non-compliance therewith.

Section 1

Within fifteen days after the date of any injury received by an employe in the course of or resulting from his employment, and within forty-eight hours of the death of an employe occurring from an injury received in the course of or resulting from his employment, the employer, whether a person, firm, or corporation, or the Commonwealth, or any political subdivision thereof, shall make report of such injury or death directly to the Department of Labor and Industry. Such report shall be made in such form as the Department of Labor and Industry shall prescribe, and shall set forth the name, address, and nature of the business of the employer; name, address, sex, age, nationality, wage or salary, and occupation of the employe; date, day of week, hour, place, cause, and character of the injury or death, and in the case of an injury, the nature of the injury, and the duration of the disability, or probable disability, as far as the same can be ascertained. Such employer shall, also, upon request of the Department of Labor and Industry, make such further report as may reasonably be required by it.

Section 2

Any person, firm, or corporation having knowledge of the occurrence of such personal injury or death to an employe, in the course of or resulting from his employment, who shall fail to make report as aforesaid, shall, upon conviction thereof in a summary proceeding, be sentenced to pay a fine of not more than one hundred dollars ($100.00), or undergo imprisonment for not more than thirty (30) days, or both, at the discretion of the court.

Section 3

Reports made in accordance with this act shall not be evidence against the employer in any proceeding, either under the Workmen’s Compensation Law of one thousand nine hundred and fifteen or otherwise.

Section 4

No employer who has made the report required by this act shall be required to make any other or further report of such injury or death to any other department of the government of the Commonwealth.

Section 5

This act shall not apply to casual employments; nor to injuries resulting in disability continuing less than the day shift or turn in which the injury was received.
 

Appendix C
Forms

LIBC-9Medical Report Form
LIBC-10Authorization for Alternate Delivery of Compensation Payments
LIBC-14Instructions for Religious Exception Application
LIBC-14ASection 304.2 Application for Religious Exception of Specified Employes from the Provisions of the Pennsylvania Workers’ Compensation Act
LIBC-14BEmploye’s Affidavit and Waiver of Workers’ Compensation Benefits and Statement of Religious Sect (to be filed with the §304.2 Application for Religious Exception)
LIBC-14CCertification of Religious Exception
LICB-25/26Appeal from Judge’s Findings of Fact and Conclusions of Law
LIBC-34Petition for Commutation of Compensation Under the Pennsylvania Workers’ Compensation Act of 1915 as Reenacted and Amended (Section 316)
LIBC-35Answer to Petition for Commutation
LIBC-134Dismemberment Chart - Hand
LIBC-134BDismemberment Chart - Body
LIBC-134FDismemberment Chart - Foot
LIBC-336Agreement for Compensation for Disability or Permanent Injury
LIBC-337Supplemental Agreement for Compensation for Disability or Permanent Injury
LIBC-338Agreement for Compensation for Death
LIBC-339Supplemental Agreement for Compensation for Death
LIBC-340Agreement to Stop Weekly Workers’ Compensation Payments (Final Receipt)
LIBC-344Employer’s Report of Occupational Injury or Disease
LIBC-362Claim Petition for Workers’ Compensation (Workers’ Compensation Act only)
LIBC-363Fatal Claim Petition for Compensation by Dependents of Deceased Employees
LIBC-364BDefendant’s Answer to Claim Petition Under Pennsylvania Occupational Disease Act
LIBC-374Defendant’s Answer to Claim Petition under Pennsylvania Workers’ Compensation Act
LIBC-375Claim Petition for Additional Compensation from the Subsequent Injury Fund Pursuant to Section 306.1 of the Workers’ Compensation Act
LIBC-376Petition for Joinder of Additional Defendant
LIBC-377Answer to Petition to: Review, Terminate, Modify, Suspend, Reinstate or Set Aside Final Receipt
LIBC-378Petition to: Review Medicals, Terminate, Modify, Suspend, Review, Reinstate Compensation Benefits or Set Aside Final Receipt
LIBC-380Third Party Settlement Agreement
LIBC-382Claim Petition for Compensation Under the Pennsylvania Occupational Disease Act
LIBC-384Fatal Claim Petition for Compensation by Dependents for Death Covered by the Pennsylvania Occupational Disease Act
LIBC-386Fatal Claim Petition for Compensation by Dependents for Death Resulting from Occupational Disease (except Silicosis, Anthraco-Silicosis or Asbestosis)
LIBC-392Statement of Account of Compensation Paid
LIBC-392AFinal Statement of Account of Compensation Paid
LIBC-396Occupational Disease Claim Petition (Section 301(i) of Occupational Disease Act only: Benefits for Silicosis, Anthraco-Silicosis, Coal Worker’s Pneumoconiosis or Asbestosis)
LIBC-475Certification
LIBC-480Subpoena
LIBC-494AStatement of Wages (for Injuries Occurring on or before June 23, 1996)
LIBC-494CStatement of Wages (for Injuries Occurring on or after June 24, 1996)
LIBC-495Notice of Compensation Payable
LIBC-496Notice of Workers’ Compensation Denial
LIBC-497Physician’s Affidavit of Recovery
LIBC-498Commutation of Compensation (Section 412)
LIBC-499Petition for Physical Examination or Expert Interview of Employee (Section 314)
LIBC-500Remember: It is Important to Tell Your Employer About Your Injury (insurance posting form)
LIBC-501Notice of Temporary Compensation Payable
LIBC-502Notice Stopping Temporary Compensation
LIBC-507Application for Fee Review Pursuant to Section 306(f.1)
LIBC-509Application for Executive Officer Exception from the Provisions of the Pennsylvania Workers’ Compensation Act: Section 104
LIBC-510Employer’s Application to Elect Domestic Employees to Come Within Provisions of the Workers’ Compensation Act: Section 321
LIBC-513Executive Officer’s Declaration (Affidavit)
LIBC-524Defendant’s Answer to Occupational Disease Claim Petition
LIBC-550Claiim Petition for Benefits from the Uninsured Employer Guaranty Fund and Uninsured Employer
LIBC-551Notice of Claim Against Uninsured Employer
LIBC-601Utilization Review Request
LIBC-603Petition for Review of Utilization Review Determination
LIBC-604Utilization Review Determination Face Sheet
LIBC-620Peer Review Request
LIBC-646Claimant’s Occupational Disease Questionnaire
LIBC-661Employer’s Certificate of Insurance
LIBC-662Application for Supersedeas Fund Reimbursement
LIBC-686Petition for Penalties
LIBC-750Employee Report of Wages and Physical Condition (Wages other than Workers’ Compensation Benefits Received)
LIBC-751Notification of Suspension or Modification and Insurer’s Affidavit Pursuant to §§ 413 (C) & (D)
LIBC-753Notice of Request for an Informal Conference
LIBC-754Informal Conference Agreement Form
LIBC-755Compromise and Release Agreement by Stipulation Pursuant to Section 449 of the Workers’ Compensation Act
LIBC-756Employee’s Report of Benefits (Unemployment Compensation, Social Security (Old Age), Severance and Pension Benefits) for Offsets
LIBC-757Notice of Ability to Return to Work
LIBC-758Notice to Claimant
LIBC-760Employee Verification of Employment, Self-Employment or Change in Physical Condition
LIBC-761Notice of Workers’ Compensation Benefit Offset
LIBC-762Notice of Suspension for Failure to Return Form LIBC-760
LIBC-763Notice of Reinstatement of Workers’ Compensation Benefits
LIBC-764Notice of Change of Workers’ Compensation Disability Status
LIBC-765Impairment Rating Evaluation Appointment
LIBC-766Request for Designation of a Physician to Perform an Impairment Rating Evaluation
LIBC-767Impairment Rating Determination Face Sheet
 

Appendix D
Statewide Average Weekly Wage

The maximum weekly compensation payable is defined as the Statewide average weekly wage. See sections 105.1 and 105.2. The following schedule reflects the maximum weekly benefit:
 
May 1, 1972 through December 31, 1972 - $141.00
January 1, 1973 through December 31, 1973 - $150.00
January 1, 1974 through December 31, 1974 - $159.00
January 1, 1975 through December 31, 1975 - $171.00
January 1, 1976 through December 31, 1976 - $187.00
January 1, 1977 through December 31, 1977 - $199.00
January 1, 1978 through December 31, 1978 - $213.00
January 1, 1979 through December 31, 1979 - $227.00
January 1, 1980 through December 31, 1980 - $242.00
January 1, 1981 through December 31, 1981 - $262.00
January 1, 1982 through December 31, 1982 - $284.00
January 1, 1983 through December 31, 1983 - $306.00
January 1, 1984 through December 31, 1984 - $320.00
January 1, 1985 through December 31, 1985 - $336.00
January 1, 1986 through December 31, 1986 - $347.00
January 1, 1987 through December 31, 1987 - $361.00
January 1, 1988 through December 31, 1988 - $377.00
January 1, 1989 through December 31, 1989 - $399.00
January 1, 1990 through December 31, 1990 - $419.00
January 1, 1991 through December 31, 1991 - $436.00
January 1, 1992 through December 31, 1992 - $455.00
January 1, 1993 through December 31, 1993 - $475.00
January 1, 1994 through December 31, 1994 - $493.00
January 1, 1995 through December 31, 1995 - $509.00
January 1, 1996 through December 31, 1996 - $527.00
January 1, 1997 through December 31, 1997 - $542.00
January 1, 1998 through December 31, 1998 - $561.00
January 1, 1999 through December 31, 1999 - $588.00
January 1, 2000 through December 31, 2000 - $611.00
January 1, 2001 through December 31, 2001 - $644.00
January 1, 2002 through December 31, 2002 - $662.00
January 1, 2003 through December 31, 2003 - $675.00
January 1, 2004 through December 31, 2004 - $690.00
January 1, 2005 through December 31, 2005 - $716.00
January 1, 2006 through December 31, 2006 - $745.00
January 1, 2007 through December 31, 2007 - $779.00
January 1, 2008 through December 31, 2008 - $807.00
January 1, 2009 through December 31, 2009 - $836.00
 
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