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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
34 Petition for Commutation
WCOA
Web/Fillable
Mail
Upload or mail - no WCAIS screens
Y
2/2018
 
112 WC Hearing - Interested Party Update Request Instructions  
 
 
N/A
N/A
N/A
N/A
 
113 WC Hearing - Interested Party Update Request  
 
 
Hand deliver to hearing
N/A
N/A
 
35 Answer to Petition for Commutation  
 
 
Upload or mail - no WCAIS screens
Y
6/30/2014
 
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
 
552 Authorization to Release Information
UEGF/WCOA
Web/Fillable
Online/Mail
WCAIS screens or mail
N/A
2/2018
 
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