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Quick Reference Guide to LIBC Forms BWC and OCR

BWC 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

9Workers' Compensation Medical Report Form

BWC/Healthcare Services

Web/Fillable

Online/Mail

P

I

A1, A6

N

3/31/2014

 
10Authorization for Alternative Delivery of Compensation Payments

BWC/Claims

Web

Online/Mail

P

I

N/A

Yes, if form is used

6/30/2014

 
14Instructions for Religious Exception Application

BWC/Compliance

Web

Online/Mail

P

N/A

N/A

N

N/A

 
14AApplication 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

 
14BEmployee'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

 
90Electronic Data Interchange First Report of Injury

BWC/Claims

N/A

Online

P

N/A

A5

Y

N/A

 
134Dismemberment Chart

BWC/Healthcare Services

Web

Online/Mail

P

I

N/A

Yes, if form is used

N/A

 
134FDismemberment Chart

BWC/Healthcare Services

Web

Online/Mail

P

I

N/A

Yes, if form is used

N/A

 
210IInsurer’s Annual Report of Accident & Illness Prevention Services

Health & Safety

Web

Online/Mail

P

I

A7

N

N/A

 
211IInsurer’s Initial Report of Accident & Illness Prevention Services

Health & Safety

Web

Online/Mail

P

I

A7

N

N/A

 
221ISelf-Insured Employer's Initial Report of Accident and Illness Prevention Program

Health & Safety

Web

Online/Mail

P

I

A7

N

N/A

 
230GAnnual Report of Accident and Illness Prevention Program Status by Group Self-Insurance Funds

 

 

 

P

I

A7

N

6/30/2014

 
231GInitial Report of Accident and Illness Prevention Program Status by New Group Self-Insurance Funds

 

 

 

P

I

A7

N

6/30/2014

 
336Agreement for Compensation for Disability or Permanent Injury

BWC/Claims

Web/Fillable

Upload

P

I

A1, A2, A6

Y

6/30/2014

 
337Supplemental Agreement for Compensation for Disability or Permanent Injury

BWC/Claims

Web/Fillable

Online/Mail

P

I

A1, A2, A6

Y

6/30/2014

 
338Agreement for Compensation for Death

BWC/Claims

Web/Fillable

Online/Mail

P

I

A1, A2, A6

Y

6/30/2014

 
339Supplemental Agreement for Compensation for Death

BWC/Claims

Web/Fillable

Online/Mail

P

I

A1, A2, A6

Y

6/30/2014

 
340Agreement to Stop Weekly Workers' compensation Payments Final Receipt

BWC/Claims

Web/Fillable

Online/Mail

P

I

A1, A2, A6

Y

6/30/2014

 
350Annual Contribution Worksheet Group Self-Insurance Fund Member Annual Contribution Worksheet Form

BWC/Self-Insurance

Web/Fillable

Upload

Excel

 

A7

N

9/9/2013

 
351Expense Loss Cost Multiplier Worksheet for Group Self-Insurance Fund Using Rating Organization Loss Costs Multiplier Calculation Worksheet and Instructions

BWC/Self-Insurance

Web/Fillable

Upload

Excel

 

A7

N

9/9/2013

 
352Expense 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

Upload

Excel

 

A7

N

9/9/2013

 
365Supplemental Information Addendum to Group Self-Insurance Fund Annual Report

BWC/Self-Insurance

Web/Fillable

Upload

P

I

A7

N

9/9/2013

 
368Supplemental 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

 
369Supplemental Information Addendum to Application as a Group Workers' Compensation Fund

BWC/  Self-Insurance

Web/Fillable

Upload

P

I

A7

N

9/9/2013

 
371Supplemental Information Addendum to Annual Report of Runoff Group Self-Insurance Fund

BWC/Self-Insurance

Web/Fillable

Upload

P

I

A7

N

9/9/2013

 
380Third Party Settlement Agreement

 

 

 

P

I

A1, A2, A6

Y

6/30/2014

 
392AFinal Statement of Account of Compensation Paid

 

 

 

P

I

A5

Y

N/A

 
494AStatement 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

 
494CStatement 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

 
495Notice of Compensation Payable

BWC/Claims

PDF

EDI Generated

N/A

N/A

A5

N/A

N/A

 
496Notice of Workers' Compensation Denial

BWC/Claims

PDF

EDI Generated

N/A

N/A

A5

N/A

N/A

 
498Commutation of Compensation

 

 

 

P

I

A5

Y

N/A

 
500Remember:  It is Important to Tell Your Employer About Your Injury

BWC/Healthcare Services

Web

Online/    Mail

P

I

N/A

N

N/A

 
501Notice of Temporary Compensation Payable

BWC/Claims

PDF

EDI Generated

N/A

N/A

A5

N/A

N/A

 
502Notice Stopping Temporary Compensation

BWC/Claims

PDF

EDI Generated

N/A

N/A

A5

N/A

N/A

 
551Notice of Claim Against Uninsured Employer

 

 

 

P

 

 

 

 

 

 
604Utilization Review Determination Face Sheet

 

 

 

P

N/A

A1

Y

3/31/2014

 
750Employee Report of Wages

BWC/Healthcare Services

Web

Online/Mail

P

I

N/A

Yes, if form is used

6/30/2014

 
751Notification of Suspension or Modification Pursuant to 413(c) & (d)

BWC/Claims

Web/Fillable

Upload  Mail

P

I

A1, A2, A4, A6

Y

6/30/2014

 
756Employee's Report of Benefits for Offsets

BWC/Healthcare Services

Web

Online/Mail

P

I

N/A

Yes, if form is used

6/30/2014

 
760Employee 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

 
761Notice of Workers' Compensation Benefit Offset

 

 

 

P

I

A5

Y

6/30/2014

 
762Notice of Suspension-Failure to Return Form LIBC-760

 

 

 

P

I

A5

Y

N/A

 
763Notice of Reinstatement of Workers' Compensation Benefits

 

 

 

P

I

A5

Y

N/A

 
810Claims 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

 

OCR Forms

OCR forms must be completed in black ink with one letter per block
 
507Application for Fee Review Pursuant to Section 306(F.1) - OCR

BWC/Healthcare Services

OCR
Web/Fillable

Online
Mail

P

I

A4, A6

N

4/1/2016

 
509Application for Executive Officer's Declaration - OCR

BWC/Compliance

OCR
Web/Fillable

Online
Mail

P

I

A1, A4, A6

N

6/1/2015

 
513Executive Officer's Declaration - OCR

BWC/Compliance

OCR
Web/Fillable

Upload/Mail

P

I

A1, A4, A6

N

9/9/2013

 
601Utilization Review Request - OCR

BWC/UEGF

OCR
Web/Fillable

Online
Mail

P

I

A4, A6

Y

4/1/2016

 
601Instructions for Completing Utilization Review Request

BWC/UEGF

Web

Online
Mail

P

N/A

N/A

N

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) Submit forms electronically through a batch transmission process. The forms must be submitted one form per file and all files would be submitted to the pre-approved, and assigned SFTP folder.
 3) Electronic Forms Application: Stakeholders (Insurer, Claim Administrator, Attorney) can log-in to the WCAIS forms application, complete forms LIBC- 494C, LIBC-495, LIBC-496, LIBC-501, LIBC-502, and submit the forms. The form will be attached to the claim in WCAIS.
 4) WCAIS Screen completion, stakeholders can complete the online version of the form in WCAIS and submit the form using the WCAIS system process.
 5) The EDI transaction will be acceptable as bureau notification. No form will need to be sent to the Bureau.
 6) Hard copy form can be mailed to the Bureau.
 7) Form submitted with the electronic filing of the Self-Insurance Application.