Quick Reference Guide to LIBC FormsBWC Forms |
| Form (LIBC) Number | Form Name | Program Area | Format | WCAIS Usage | Print
(P) | Interactive
(I) | Submission
Method
(Ledger A) | Form must be sent to Claimant / Injured Worker
(Y or N) | Revised form must be used by this date |
|---|
| 9 | Workers' Compensation Medical Report Form | BWC/Healthcare Services | Web/Fillable | Online/Mail |
P |
I | A1, A6 | N | 3/31/2014 |
| |
| 10 | Authorization for Alternative Delivery of Compensation Payments | BWC/Claims | Web | Online/Mail |
P |
I | N/A | Yes, if form is used | 6/30/2014 |
| |
| 14 | Instructions for Religious Exception Application | BWC/Compliance | Web | Online/Mail |
P | N/A | N/A | N | N/A |
| |
| 14A | Application for Religious Exception of Specified Employees from the Provisions of the PA worker's Comp Act | BWC/Compliance | Web/Fillable | Online/Mail |
P |
I | A1, A4, A6 | N | N/A |
| |
| 14B | Employee's Affidavit and Waiver of Workers' Compensation Benefits and Statement of religious Sect | BWC/Compliance | Web/Fillable | Online/Mail |
P |
I | A1, A4, A6 | N | N/A |
| |
| 20 | Employers Panel Provider Requirements | BWC/Healthcare Services | N/A | N/A |
P | N/A | N/A | N | N/A |
| |
| 90 | Electronic Data Interchange First Report of Injury | BWC/Claims | N/A | Online |
P |
I | A5 | Y | N/A |
| |
| 118 | Application for Benefits Under Section 909 of the Workers’ Compensation Act | BWC-Self-Insurance | N/A | Online/Mail |
P | N/A | A6 | N | N/A |
| |
| 131 | Qualifications of Reviewer | BWC/Healthcare Services | Web | Online |
P |
I | A1 | N | N/A |
| |
| 134 | Dismemberment Chart | BWC/Healthcare Services | Web | Online/Mail |
P |
I | N/A | Yes, if form is used | N/A |
| |
| 134F | Dismemberment Chart | BWC/Healthcare Services | Web | Online/Mail |
P |
I | N/A | Yes, if form is used | N/A |
| |
| 210I | Insurer’s Annual Report of Accident & Illness Prevention Services | Health & Safety | Web | Online/Mail |
P |
I | A7 | N | N/A |
| |
| 211I | Insurer’s Initial Report of Accident & Illness Prevention Services | Health & Safety | Web | Online/Mail |
P |
I | A7 | N | N/A |
| |
| 220E | Annual Report of Accident & Illness Prevention Program Status by Individual Self-Insured Employers | Health & Safety | Web/Fillable | Online |
P |
I | N/A | N | N/A |
| |
| 221I | Self-Insured Employer's Initial Report of Accident and Illness Prevention Program | Health & Safety | Web | Online/Mail |
P |
I | A7 | N | N/A |
| |
| 230G | Annual Report of Accident and Illness Prevention Program Status by Group Self-Insurance Funds | | | |
P |
I | A7 | N | 6/30/2014 |
| |
| 231G | Initial Report of Accident and Illness Prevention Program Status by New Group Self-Insurance Funds | | | |
P |
I | A7 | N | 6/30/2014 |
| |
| 336 | Agreement for Compensation for Disability or Permanent Injury | BWC/Claims | Web/Fillable | Upload |
P |
I | A1, A2, A6 | Y | 6/30/2014 |
| |
| 337 | Supplemental Agreement for Compensation for Disability or Permanent Injury | BWC/Claims | Web/Fillable | Online/Mail |
P |
I | A1, A2, A6 | Y | 6/30/2014 |
| |
| 338 | Agreement for Compensation for Death | BWC/Claims | Web/Fillable | Online/Mail |
P |
I | A1, A2, A6 | Y | 6/30/2014 |
| |
| 339 | Supplemental Agreement for Compensation for Death | BWC/Claims | Web/Fillable | Online/Mail |
P |
I | A1, A2, A6 | Y | 6/30/2014 |
| |
| 340 | Agreement to Stop Weekly Workers' compensation Payments Final Receipt | BWC/Claims | Web/Fillable | Online/Mail |
P |
I | A1, A2, A6 | Y | 6/30/2014 |
| |
| 350 | Annual Contribution Worksheet Group Self-Insurance Fund Member Annual Contribution Worksheet Form | BWC/Self-Insurance | Web/Fillable | Upload | Excel | | A7 | N | 9/9/2013 |
| |
| 351 | Expense Loss Cost Multiplier Worksheet for Group Self-Insurance Fund Using Rating Organization Loss Costs Multiplier Calculation Worksheet and Instructions | BWC/Self-Insurance | Web/Fillable | Online |
Sample
| | A7 | N | 9/9/2013 |
| |
| 352 | Expense Loss Cost Multiplier Worksheet for Group Self-Insurance Fund Deviating From Rating Organization Loss Costs Multiplier Calculation Worksheet and Instructions | BWC/Self-Insurance | Web/Fillable | Online
|
Sample
| | A7 | N | 9/9/2013 |
| |
| 365 | Supplemental Information Addendum to Group Self-Insurance Fund Annual Report | BWC/Self-Insurance | Web/Fillable | Upload |
P |
I | A7 | N | 9/9/2013 |
| |
| 368 | Supplemental Information Addendum to Application for Membership in a Group Workers' Compensation Fund | BWC/Self-Insurance | Web/Fillable | Upload |
P |
I | A7 | N | 9/9/2013 |
| |
| 369 | Supplemental Information Addendum to Application as a Group Workers' Compensation Fund | BWC/ Self-Insurance | Web/Fillable | Upload |
P |
I | A7 | N | 9/9/2013 |
| |
| 371 | Supplemental Information Addendum to Annual Report of Runoff Group Self-Insurance Fund | BWC/Self-Insurance | Web/Fillable | Upload |
P |
I | A7 | N | 9/9/2013 |
| |
| 380 | Third Party Settlement Agreement | | | |
P |
I | A1, A2, A6 | Y | 6/30/2014 |
| |
| 392A | Final Statement of Account of Compensation Paid | | | |
P |
I | A5 | Y | N/A |
| |
| 494A | Statement of Wages (For Injuries Occurring On or Before June 23, 1996) | BWC/Claims | Web/Fillable | Upload/Mail |
P |
I | A1, A2, A6 | Y | 6/30/2014 |
| |
| 494C | Statement of Wages (For Injuries Occurring On or After June 24, 1996) | BWC/Claims | Web/Fillable | Upload/Mail |
P |
I | A1, A2, A3, A6 | Y | 6/30/2014 |
| |
| 495 | Notice of Compensation Payable | BWC/Claims |
PDF | EDI Generated | N/A | N/A | A5 | N/A | N/A |
| |
| 495B | Notice of Compensation Payable | BWC/Claims |
PDF | EDI Generated | N/A | N/A | A5 | N/A | N/A |
| |
| 496 | Notice of Workers' Compensation Denial | BWC/Claims |
PDF | EDI Generated | N/A | N/A | A5 | N/A | N/A |
| |
| 498 | Commutation of Compensation | | | |
P |
I | A5 | Y | N/A |
| |
| 500 | Remember: It is Important to Tell Your Employer About Your Injury | BWC/Healthcare Services | Web | Online/ Mail |
P |
I | N/A | N | N/A |
| |
| 500(ESP) | Recuerde: Es Importante Informarle A Su Empleador Sobre Su Lesion | BWC/Servicios de atención médica | Web | Online/Correo electrónico |
P |
I | Non Aplicable | N | Non Aplicable |
| |
| 501 | Notice of Temporary Compensation Payable | BWC/Claims |
PDF | EDI Generated | N/A | N/A | A5 | N/A | N/A |
|
| |
| 502 | Notice Stopping Temporary Compensation | BWC/Claims |
PDF | EDI Generated | N/A | N/A | A5 | N/A | N/A |
| |
| 551 | Notice of Claim Against Uninsured Employer | | | |
P |
| | | |
| |
| 604 | Utilization Review Determination Face Sheet | | | |
P |
I | A1 | Y | 3/31/2014 |
| |
| 750 | Employee Report of Wages | BWC/Healthcare Services | Web | Online/Mail |
P |
I | N/A | Yes, if form is used | 6/30/2014 |
| |
| 751 | Notification of Suspension or Modification Pursuant to 413(c) & (d) | BWC/Claims | Web/Fillable | Upload Mail |
P |
I | A1, A2, A4, A6 | Y | 2/13/2023
|
|
| 756 | Employee's Report of Benefits for Offsets | BWC/Healthcare Services | Web | Online/Mail |
P |
I | N/A | Yes, if form is used | 6/30/2014 |
| |
| 760 | Employee Verification of Employment, Self-Employment or Change in Physical Condition | BWC/Healthcare Services | Web | Online/Mail |
P |
I | N/A | Yes, if form is used | 6/30/2014 |
| |
| 761 | Notice of Workers' Compensation Benefit Offset | | | |
P |
I | A5 | Y | 6/30/2014 |
| |
| 762 | Notice of Suspension-Failure to Return Form LIBC-760 | | | |
P |
I | A5 | Y | N/A |
| |
| 763 | Notice of Reinstatement of Workers' Compensation Benefits | | | |
P |
I | A5 | Y | N/A |
| |
| 764 | Notice of Change of Workers’ Compensation Disability Status (Electronic Data Interchange) | BWC/Healthcare Services | Web/Fillable | Upload/EDI |
P |
I | A1 | Y | 1/1/2019 |
| |
| 765 | Impairment Rating Evaluation Appointment | BWC/Healthcare Services | Web |
Online | N/A | N/A | A3 | Y | 1/1/2019 |
| |
| 766 | Request for Designation of a Physician to Perform an Impairment Rating Evaluation | BWC/Healthcare Services | Web |
Online
| N/A | N/A | A3 | Y | 1/1/2019 |
| |
| 767 | Impairment Rating Determination Face Sheet | BWC/Healthcare Services | Web/Fillable | Upload/Online |
P |
I | A1,A4 | Y | 1/1/2019 |
| |
| 810 | Claims Listing Template | BWC/Self-Insurance | Excel
(download from WCAIS only) | Upload
Mail | Excel | N/A | A7 | N | 9/9/2013 |
| |
| | Notice: Medical Treatment for Your Work Injury or Occupational Illness | | | |
P | N/A | N/A | Yes, if form is used | N/A |
| |
|
These forms must be completed in black ink with one letter per block. |
| |
| 507 | Application for Fee Review Pursuant to Section 306(F.1) - OCR | BWC/Healthcare Services | Web/Fillable | Online
Mail |
P |
I | A4, A6 | N | 4/1/2016 |
| |
| 509 | Application for Executive Officer's Declaration - OCR | BWC/Compliance | Web/Fillable | Online
Mail |
P |
I | A1, A4, A6 | N | 6/1/2015 |
| |
| 513 | Executive Officer's Declaration - OCR | BWC/Compliance | Web/Fillable | Upload/Mail |
P |
I | A1, A4, A6 | N | 9/9/2013 |
| |
| 601 | Utilization Review Request | BWC/UEGF | |
| |
Sample | A4, A6 | Y | 4/1/2016 |
|
| |
| | Ledger A - Methods available for Bureau Notification |
| | 1) Upload in the WCAIS system by logging in and attaching a document to the claim. |
| | 2) Claim Administrators and Attorneys may log in to WCAIS on the Actions tab to generate an LIBC-494C to submit the form and attach it to the claim in WCAIS. |
| | 3) WCAIS Screen completion, stakeholders can complete the online version of the form in WCAIS and submit the form using the WCAIS system process. |
| | 4) An EDI transaction will be acceptable as bureau notification and no form will need to be sent to the bureau. Adjusters should refer to the PA Implementation Guide for information on which forms this applies. |
| | 5) Hard copy form can be mailed to the Bureau. |
| | 6) Form submitted with the electronic filing of the Self-Insurance Application. |
| | 7) Submission of an accepted EDI transaction to complete the LIBC-495, LIBC-496, LIBC-501 & LIBC-502. |