Notice of Workers' Compenation Denial, LIBC-496

The Department of Labor & Industry, Bureau of Workers' Compensation, has revised the Notice of Workers’ Compensation Denial, form LIBC-496, by making the following changes: medical-only claims can no longer be filed via this form; the language in number four has been revised; a portion of the language in number six has been stricken; and the information regarding physicians’ reports removed.
 
After June 20, 2011, prior versions of the form will not be accepted by the bureau and will be returned to you.
 
Please be aware that with the revision of this form, it may no longer be used to accept medical only claims. The purpose behind the changes to the LIBC-496 is to provide clarity by eliminating the confusion and potential for unnecessary litigation in prior situations where an employer or insurer would “accept” an injury by issuing a "denial" form.
An electronic version of the revised Notice of Workers' Compensation Denial and reproduction instructions to be used by your printing contractor are available online.
 
Please note that all bureau forms must be tested and approved by the bureau for formatting prior to use.
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