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 |