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Quick Reference Guide to LIBC Forms WCOA

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