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WC CLAIM FORMS

A First Report of Injury (FROI) electronic data interchange or Web portal transaction is required to establish a claim in the Workers' Compensation Automation and Integration System, or WCAIS. Forms received by the Bureau of Workers' Compensation prior to submission of the initial FROI transaction cannot be uploaded by the bureau into WCAIS, as there is no claim established in the system to which the form can be attached or filed.

Please remember: For all data and information which is submitted to the department via EDI, Web portal and/or upload, in connection with a filing for which a copy is required by law to be provided to another party, a true and correct copy still must be provided to that party consistent with the Act, regulations and/or any applicable department-issued policy statement or written guidance.

More information on electronic filing in WCAIS, including form format, can be found in Section 2.1, "Electronic Data Reporting Format," of the EDI Claims Implementation Guide.

Forms required to be filed with BWC can be provided in one of several ways:

  • Soft file batch transmission, or
  • Electronically attaching to the individual claim, or
  • Utilization of the WCAIS electronic forms application to complete forms: LIBC-494C, LIBC-495, LIBC-496, LIBC-501, LIBC-502 (stakeholders), or
  • Hard copy via US Postal Service

NOTE: WCAIS has a screen for the LIBC-751, Notification of Suspension or Modification that will collect the required information and create the form that must then be printed, signed and notarized by the claim administrator and uploaded into WCAIS. A copy of this form must also be sent to the injured worker

SUBMITTING REQUIRED FORMS

The following forms are required to be submitted to the bureau, as submission of the EDI transactions alone do not satisfy the filing requirements under the PA Workers' Compensation Act:

  1. LIBC-336 Agreement for Compensation for Disability or Permanent Injury
  2. LIBC-337 Supplemental Agreement for Compensation for Disability or Permanent Injury
  3. LIBC-338 Agreement for Compensation for Death
  4. LIBC-339 Supplemental Agreement for Compensation for Death
  5. LIBC-340 Agreement to Stop Weekly Workers' Compensation Payments (Final Receipt)
  6. LIBC-380 Third Party Settlement Agreement

In addition to the EDI transaction, the forms listed below must be sent to the injured worker and filed with the bureau. Written notice to the injured worker has not changed due to implementation of EDI Release 3, and is still required.

  1. LIBC-494C Statement of Wages (For Injuries Occurring On or After June 24, 1996)
  2. LIBC-495 Notice of Compensation Payable
  3. LIBC-496 Notice of Workers' Compensation Denial
  4. LIBC-501 Notice of Temporary Compensation Payable
  5. LIBC-502 Notice Stopping Temporary Compensation (WCAIS has a screen that will collect the LIBC-502 information and create the form that the claim administrator must print and send to the injured worker.)

SUBMITTING PAPER FORMS

  1. All two-sided forms (duplex) should be submitted as a single sheet, duplex form.
  2. Use a medium point black ink pen on all forms or have them typed.
  3. Do not use colored paper.
  4. List the appropriate county on the forms when requested.
  5. Please double-check the accuracy of the information provided, such as employee name, address and Social Security Number, employer name and address, insurance information, injury date and description of injury.
  6. Employee signature on the Notice of Suspension or Modification form (Form LIBC-751) is required only if employee is intending to create an employee challenge and request a special hearing regarding the suspension or modification. Employee signature should appear when the employee challenge box is checked.
  7. Signatures are required on some forms. This is a mandatory requirement if requested on the form.

FORMS NO LONGER NEEDED

The following forms are available for download from the Department of Labor & Industry website. These forms will not be filed with the bureau because an EDI transaction satisfies the bureau reporting requirement in the scenarios identified in the PA Claims EDI Release 3 Event Table. However, a copy of the information submitted via the EDI transaction must be sent to the employee/claimant as required by the PA Workers' Compensation Act.

Claim administrators may use LIBC forms currently generated by their system or, for FROI transactions, the LIBC-90 generated by WCAIS. The forms listed below may also be used and can be downloaded from the department's website.

Form Description
LIBC-392A FINAL STATEMENT OF ACCOUNT OF COMPENSATION PAID
LIBC-498 COMMUTATION OF COMPENSATION
LIBC-761 NOTICE OF WORKERS' COMPENSATION BENEFIT OFFSET
LIBC-762 NOTICE OF SUSPENSION FOR FAILURE TO RETURN FORM LIBC-760
LIBC-763 NOTICE OF REINSTATEMENT OF WORKERS' COMPENSATION BENEFITS

ANSWERS TO PETITIONS

We encourage you to submit the answers to petitions directly to the workers' compensation judge assigned to the case.

SUPPLEMENTAL AGREEMENT FOR COMPENSATION FOR DISABILITY OR PERMANENT INJURY

If you are using a single supplemental agreement to report multiple periods, list the most recent period of payment on the front of the form and subsequent periods of payment under "other matters agreed upon" on the reverse of the form. The claimant's signature is required for the form to be considered complete.