Quick Reference Guide to LIBC Forms WCOAWCOA Forms |
Form (LIBC) Number |
Form Name |
Program Area |
Format |
WCAIS Usage |
Print (P) |
Interactive (I) |
Submission Method |
Form must be sent to Claimant / Injured Worker (Y or N) |
Revised form must be used by this date |
---|
34 | Petition for Commutation | WCOA | Web/Fillable | Mail | | | Upload or mail - no WCAIS screens | Y | 2/2018 |
|
35 | Answer to Petition for Commutation |
|
|
| | | Upload or mail - no WCAIS screens | Y | 6/30/2014 |
|
113 | WC Hearing - Interested Party Update Request |
|
|
| | | Hand deliver to hearing | N/A | N/A |
|
362 | Claim Petition for Workers' Compensation |
|
|
| | | WCAIS screens or mail | N/A | 6/30/2104 |
|
363 | Fatal Claim Petition for Compensation by Dependents of Deceased Employees | WCOA | Web/Fillable | Upload Mail | | | Upload or mail - no WCAIS screens | N/A | 6/30/2014 |
|
364B | Defendant's Answer to Claim Petition Under Pennsylvania Occupational Disease Act | WCOA | Web/Fillable | Upload Mail | | | WCAIS screens or mail | Y | 6/30/2014 |
|
374 | Defendant's Answer to Claim Petition under Pennsylvania Workers' Compensation | WCOA | Web/Fillable | Upload/Mail | | | WCAIS screens or mail | Y | 6/30/2014 |
|
375 | Claim Petition or Additional Compensation From the Subsequent Injury Fund Pursuant to Section 306.1 of the Workers' Compensation Act | WCOA | Web/Fillable | Upload/Mail | | | Upload or mail - no WCAIS screens | N/A | 6/30/2014 |
|
376 | Petition for Joinder of Additional Defendant | WCOA | Web/Fillable | Upload/Mail | | | Upload or mail - no WCAIS screens | Y | 6/30/2014 |
|
377 | Answer to Petition To/For | WCOA | Web/Fillable | Upload/Mail | | | WCAIS screens or mail | Y | 6/30/2014 |
|
378 | Petition TO/FOR: (Check any that apply) | WCOA | Web/Fillable | Mail | | | WCAIS screens or mail | Y | 6/30/2014 |
|
384 | Fatal Claim Petition for Compensation by Dependents for Death Covered by the Pennsylvania Occupational Disease Act | WCOA | Web/Fillable | Upload | Please contact the BWC Helpline to obtain this form | Please contact the BWC Helpline to obtain this form | Please contact the BWC Helpline to obtain this form. | N/A | 6/30/2014 |
|
386 | Fatal Claim Petition for Compensation by Dependents For Death Resulting From Occupational Disease | WCOA | Web/Fillable | Upload/Mail | Please contact the BWC Helpline to obtain this form | Please contact the BWC Helpline to obtain this form | Please contact the BWC Helpline to obtain this form. | N/A | 6/30/2014 |
|
387 | Important Information About the Petition Filing and Hearing Process | WCOA | Web | N/A | | N/A | N/A | N/A | N/A |
|
396 | Occupational Disease Claim Petition Monthly Compensation for Disability Under Section 301(i) Only | WCOA | Web/Fillable | Upload/Mail | | | Upload or mail - no WCAIS screens | N/A | 6/30/2014 |
|
480 | Subpoena |
|
|
| | N/A | WCAIS screens or mail | N/A | N/A |
|
497 | Physician's Affidavit of Recovery |
|
|
| | | Upload or mail - no WCAIS screens | Y | 6/30/2014 |
|
499 | Petition for Physical Examination or Expert Interview of Employee (Section 314) | WCOA | Web/Fillable | Mail | | | WCAIS screens or mail | Y | 6/30/2014 |
|
504 | Child Support Lien Affidavit |
|
|
| | | Hand deliver to hearing, upload or mail - no WCAIS screens | Y | 2/1/2015 |
|
524 | Defendant's Answer to Occupational Disease Claim Petition Section 301(i) Only | WCOA | Web/Fillable | Upload/Mail | | | WCAIS screens or mail | Y | 6/30/2014 |
|
550 | Claim Petition for Benefits from the Uninsured Employer and the Uninsured Employers Guaranty Fund | UEGF/WCOA | Web/Fillable | Online/Mail | | | WCAIS screens or mail | N/A | 4/2017 |
|
551 | Notice of Claim Against Uninsured Employer | UEGF/WCOA | Web/Fillable | Online/Mail | | | WCAIS screens or mail | N/A | 9/2017 |
|
603 | Petition for Review of Utilization Review Determination | WCOA | Web/Fillable | Mail | | | WCAIS screens or mail | Y | 6/30/2014 |
|
606 | Request for Hearing to Contest Fee Review Determination | WCOA | Web/Fillable | Upload/Mail | | | Upload or mail - no WCAIS screens | N | 6/30/2014 |
|
749 | Death Claim Supplement to Compromise and Release Agreement |
|
|
| | N/A | Upload or mail - no WCAIS screens | N/A | 6/30/2014 |
|
753 | Notice of Request for an Informal Conference | WCOA | Web/Fillable | Upload/Mail | | | Upload or mail - no WCAIS screens | Y | 6/30/2014 |
|
754 | Informal Conference Agreement Form | WCOA | Web/Fillable | Upload/Mail | | | N/A | N/A | N/A |
|
755 | Compromise and Release Agreement by Stipulation Pursuant to Section 449 of the Workers' Compensation Act | WCOA | Web/Fillable | Upload/Mail | | | Upload or mail - no WCAIS screens | N/A | 9/2017 |
|
757 | Notice of Ability To Return To Work | BWC/Healthcare Services | Web | Online/Mail | | | Upload or mail - no WCAIS screens | Y | 6/30/2014 |
|
758 | Notice to Employee-Note: This form is to be attached to the LIBC-378 |
|
|
| | N/A | N/A | Y | N/A |