Workers' Compensation

Claim Petition for Benefits From the Uninsured Employer and the Uninsured Employers Guaranty Fund, LIBC-550 and Notice of Claim Against Uninsured Employer, LIBC-551

 
The Department of Labor & Industry, Bureau of Workers' Compensation, has revised the Claim Petition for Benefits From the Uninsured Employer and the Uninsured Employers Guaranty Fund, form LIBC-550, by making the following changes: change in the form's title; adding fields for fatality information; altering wage request information to reflect weekly wages; and updating the fraud language.
 
We have also revised the Notice of Claim Against Uninsured Employer, form LIBC-551, by making the following changes: modifying the questions in the injury and disability sections; correcting the title of the LIBC-550 in the instructions; and updating the verification language.
 
After Aug. 30, 2011, prior versions of the form will not be accepted by the bureau and will be returned to you.
 
Electronic versions of the revised Claim Petition for Benefits From the Uninsured Employer and the Uninsured Employers Guaranty Fund and the Notice of Claim Against Uninsured Employer and reproduction instructions are available online.
 
Please note that these are non-OCR forms and do not need to be tested and approved by the bureau for formatting prior to use.
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