Claim Forms Filed Online
The Bureau of Workers’ Compensation is pleased to offer the workers’ compensation community the ability to file the following forms electronically
Notice of Workers’ Compensation Denial (LIBC-496)
Notice of Compensation Payable (LIBC-495)
Notice of Temporary Compensation Payable (LIBC-501)
Notice Stopping Temporary Compensation (LIBC-502)
Defendant's Answer to Claim Petition under PA WC Act (LIBC-374)
Statement of Wages (LIBC-494C)
There are several benefits to electronic filing:
Forms are filed with the bureau instantaneously, improving timeliness.
The bureau will pre-populate existing party and injury information in the respective fields based on the name, social security number and date of injury provided, improving accuracy and consistency.
Filing electronically improves efficiency and saves time and money.
This online application is set up to use the bureau code to establish the proper carrier or associated parties responsible for claims. The bureau’s system uses the county of the employer, date of injury and bureau code to determine the appropriate insurer or party responsible for handling a claim, and for assignment to workers’ compensation judges if necessary. At present, the system accepts only one third-party administrator (TPA) or branch office per county. Consequently, if you have multiple TPAs handling claims in the same county, you will not have the ability to register both TPAs for that county. It is important to know that correspondence from the bureau will only be sent to the party registered with the bureau to handle claims for a specific county.
Therefore, it is critical that the information you currently have on file with the bureau, relative to your bureau code, is accurate. Changes should be directed to: Bureau of Workers’ Compensation, Attention: Claims Management Division Chief, 1171 South Cameron Street, Room 103, Harrisburg, PA 17104-2501, via e-mail at RA-CMDClaimsOps@pa.gov
or via fax at 717-705-1629.
Notice regarding the Answer to Claim Petition, LIBC-374:
This form is used to admit or deny facts alleged in a claim petition or to assert affirmative defenses to the claim. Answers to Claim Petitions shall be filed in accordance with Section 416 of the Act (77 P.S. §821) within 20 days after the date of assignment by the bureau to the workers' compensation judge.
If you submit an Answer to Claim Petition form via this Web page, do not submit a paper copy of the same to the Bureau of Workers' Compensation or to the workers' compensation judge's office.
Concurrently with its filing, a copy of the Answer to Claim Petition must be served on all unrepresented parties and on all counsel of record.
The bureau continues to work to make the workers’ compensation process more efficient, and we need your cooperation to succeed. If you have any questions or concerns, please do not hesitate to contact us, as noted above.
Thank you for your cooperation.