State of Pennsylvania Workers Compensation Forms in Word

Note, these Forms are available from the State of Pennsylvania at this link:http://www.portal.state.pa.us/portal/server.pt/community/ Forms/10421 in PDF and other Formats for free; we are just offering them in Microsoft Word for a fee in case you prefer that use.

Form # Form Name Price Buy Now
LIBC-9 Medical Report Form $40.00
LIBC-10 Authorization for Alternative Delivery of Compensation Payments $40.00
LIBC-14 Instructions for Religious Exception Application $40.00
LIBC-14A Section 304.2 Application for Religious Exception of Specified Employes from the Provisions of the Pennsylvania Workers’ Compensation Act $40.00
LIBC-14B Employe’s Affidavit and Waiver of Workers’ Compensation Benefits and Statement of Religious Sect $40.00
LIBC-134 Dismemberment Chart-Hand $40.00
LIBC-134F Dismemberment Chart-Foot $40.00
LIBC-336 Agreement for Compensation $40.00
LIBC-337 Supplemental Agreement for Compensation $40.00
LIBC-338 Agreement for Compensation for Death $40.00
LIBC-339 Supplemental Agreement for Compensation for Death $40.00
LIBC-340 Agreement to Stop (Final Receipt) $40.00
LIBC-362 Claim Petition $40.00
LIBC-363 Fatal Claim Petition $40.00
LIBC-364B Defendant’s Answer to Claim Petition Under PA Occupational Disease Act $40.00
LIBC-374 Defendant’s Answer to Claim Petition under PA Workers’ Comp. Act $40.00
LIBC-375 Claim Petition for Additional Compensation From the Subsequent Injury Fund $40.00
LIBC-376 Petition for Joinder $40.00
LIBC-377 Answer to Petition To/For: $40.00
LIBC-378 Petition To/For:-Important Notice $40.00
LIBC-380 Third Party Settlement Agreement $40.00
LIBC-384 Fatal…Covered by PA Occupational Disease Act $40.00
LIBC-386 Fatal…Resulting from Occupational Disease $40.00
LIBC-392A Final Statement of Account of Compensation Paid $40.00
LIBC-396 Occupational Disease Claim Petition (under section 301(1) only) $40.00
LIBC-480 Subpoena $40.00
LIBC-494A Statement of Wages (for injuries occurring on or before June 23, 1996) $40.00
LIBC-494C Statement of Wages (for injuries occurring on or after June 24, 1996) $40.00
LIBC-495 Notice of Compensation Payable (NCP) $40.00
LIBC-496 Notice of Workers’ Compensation Denial (NCD) $40.00
LIBC-497 Physician’s Affidavit of Recovery $40.00
LIBC-498 Commutation of Compensation $40.00
LIBC-499 Petition for Physical Examination $40.00
LIBC-500 Insurance Posting Form $40.00
LIBC-501 Notice of Temporary Compensation $40.00
LIBC-502 Notice Stopping Temporary Compensation $40.00
LIBC-507 Application for Fee Review Pursuant to Section 306 (F.1) $40.00
LIBC-510 Employer’s Application to Elect Domestic Employees to Come Within Provisions of the Workers’ Compensation Act: Section 321 $40.00
LIBC-550 Claim Petition for Benefits from the Uninsured Employer and the Uninsured Employers Guaranty Fund $40.00
LIBC-551 Notice of Claim Against Uninsured Employer $40.00
LIBC-601 Utilization Review Request (Instruction Sheet and Form) $40.00
LIBC-603 Petition to Review Utilization Review Determination $40.00
LIBC-606 Request for Hearing to Contest Fee Review Determination $40.00
LIBC-662 Application for Supersedeas Fund Reimbursement $40.00
LIBC-749 Death Claim Supplement to Compromise and Release Agreement $40.00
LIBC-750 Employee Report of Wages and Physical Condition $40.00
LIBC-751 Notice of Suspension or Modification $40.00
LIBC-753 Notice of Request for In Formal Conference $40.00
LIBC-754 In Formal Conference Agreement Form $40.00
LIBC-755 Compromise and Release Agreement $40.00
LIBC-756 Employee’s Report of Benefits for Offsets $40.00
LIBC-757 Notice of Ability to Return to Work $40.00
LIBC-758 Notice to Employee Note: This Form is to be attached to LIBC-378 ("Petition To:" Form). $40.00
LIBC-760 Employee Verification of Employment, Self-Employment $40.00
LIBC-761 Notice of Workers’ Compensation Benefit Offset $40.00
LIBC-762 Notice of Suspension-Failure to Return Form LIBC-760 $40.00
LIBC-763 Notice of Reinstatement of Workers’ Compensation Benefits $40.00
LIBC-764 Notice of Change of Workers’ Compensation Disability Status $40.00
LIBC-765 Impairment Rating Evaluation Appointment $40.00
LIBC-766 Request for Designation of a Physician to Per Form an Impairment Rating Evaluation $40.00
LIBC-767 Impairment Rating Determination Face Sheet $40.00

State of Pennsylvania Workers Compensation Forms in Word

Note, these Forms are available from the State of Pennsylvania at this link:http://www.portal.state.pa.us/portal/server.pt/community/ Forms/10421 in PDF and other Formats for free; we are just offering them in Microsoft Word for a fee in case you prefer that use.

Form # Form Name Price Buy Now
LIBC-9 Medical Report Form $40.00
LIBC-10 Authorization for Alternative Delivery of Compensation Payments $40.00
LIBC-14 Instructions for Religious Exception Application $40.00
LIBC-14A Section 304.2 Application for Religious Exception of Specified Employes from the Provisions of the Pennsylvania Workers’ Compensation Act $40.00
LIBC-14B Employe’s Affidavit and Waiver of Workers’ Compensation Benefits and Statement of Religious Sect $40.00
LIBC-134 Dismemberment Chart-Hand $40.00
LIBC-134F Dismemberment Chart-Foot $40.00
LIBC-336 Agreement for Compensation $40.00
LIBC-337 Supplemental Agreement for Compensation $40.00
LIBC-338 Agreement for Compensation for Death $40.00
LIBC-339 Supplemental Agreement for Compensation for Death $40.00
LIBC-340 Agreement to Stop (Final Receipt) $40.00
LIBC-362 Claim Petition $40.00
LIBC-363 Fatal Claim Petition $40.00
LIBC-364B Defendant’s Answer to Claim Petition Under PA Occupational Disease Act $40.00
LIBC-374 Defendant’s Answer to Claim Petition under PA Workers’ Comp. Act $40.00
LIBC-375 Claim Petition for Additional Compensation From the Subsequent Injury Fund $40.00
LIBC-376 Petition for Joinder $40.00
LIBC-377 Answer to Petition To/For: $40.00
LIBC-378 Petition To/For:-Important Notice $40.00
LIBC-380 Third Party Settlement Agreement $40.00
LIBC-384 Fatal…Covered by PA Occupational Disease Act $40.00
LIBC-386 Fatal…Resulting from Occupational Disease $40.00
LIBC-392A Final Statement of Account of Compensation Paid $40.00
LIBC-396 Occupational Disease Claim Petition (under section 301(1) only) $40.00
LIBC-480 Subpoena $40.00
LIBC-494A Statement of Wages (for injuries occurring on or before June 23, 1996) $40.00
LIBC-494C Statement of Wages (for injuries occurring on or after June 24, 1996) $40.00
LIBC-495 Notice of Compensation Payable (NCP) $40.00
LIBC-496 Notice of Workers’ Compensation Denial (NCD) $40.00
LIBC-497 Physician’s Affidavit of Recovery $40.00
LIBC-498 Commutation of Compensation $40.00
LIBC-499 Petition for Physical Examination $40.00
LIBC-500 Insurance Posting Form $40.00
LIBC-501 Notice of Temporary Compensation $40.00
LIBC-502 Notice Stopping Temporary Compensation $40.00
LIBC-507 Application for Fee Review Pursuant to Section 306 (F.1) $40.00
LIBC-510 Employer’s Application to Elect Domestic Employees to Come Within Provisions of the Workers’ Compensation Act: Section 321 $40.00
LIBC-550 Claim Petition for Benefits from the Uninsured Employer and the Uninsured Employers Guaranty Fund $40.00
LIBC-551 Notice of Claim Against Uninsured Employer $40.00
LIBC-601 Utilization Review Request (Instruction Sheet and Form) $40.00
LIBC-603 Petition to Review Utilization Review Determination $40.00
LIBC-606 Request for Hearing to Contest Fee Review Determination $40.00
LIBC-662 Application for Supersedeas Fund Reimbursement $40.00
LIBC-749 Death Claim Supplement to Compromise and Release Agreement $40.00
LIBC-750 Employee Report of Wages and Physical Condition $40.00
LIBC-751 Notice of Suspension or Modification $40.00
LIBC-753 Notice of Request for In Formal Conference $40.00
LIBC-754 In Formal Conference Agreement Form $40.00
LIBC-755 Compromise and Release Agreement $40.00
LIBC-756 Employee’s Report of Benefits for Offsets $40.00
LIBC-757 Notice of Ability to Return to Work $40.00
LIBC-758 Notice to Employee Note: This Form is to be attached to LIBC-378 ("Petition To:" Form). $40.00
LIBC-760 Employee Verification of Employment, Self-Employment $40.00
LIBC-761 Notice of Workers’ Compensation Benefit Offset $40.00
LIBC-762 Notice of Suspension-Failure to Return Form LIBC-760 $40.00
LIBC-763 Notice of Reinstatement of Workers’ Compensation Benefits $40.00
LIBC-764 Notice of Change of Workers’ Compensation Disability Status $40.00
LIBC-765 Impairment Rating Evaluation Appointment $40.00
LIBC-766 Request for Designation of a Physician to Per Form an Impairment Rating Evaluation $40.00
LIBC-767 Impairment Rating Determination Face Sheet $40.00