Form Libc 14B PDF Details

In the Commonwealth of Pennsylvania, the Department of Labor and Industry's Bureau of Workers' Compensation issues the LIBC-14B form, a critical document for those whose religious beliefs stand in contrast with the acceptance of standard workers' compensation benefits. This form serves as both an affidavit and a waiver, specifically tailored for employees who are devout members of religious sects with teachings that conscientiously object to the acceptance of any public or private insurance benefits. These benefits encompass those for death, disability, old age, retirement, or medical bills, including those under the Federal Social Security Act. By completing this form, an employee voluntarily forgoes rights to benefits under the Pennsylvania Workers’ Compensation Act, affirming their adherence to their religious beliefs. Additionally, it requires a statement from the religious sect leader, verifying the employee's active membership and the sect’s established tenets against accepting insurance benefits. This procedure not only respects the religious freedom of employees but also outlines a formal process for the waiver of workers' compensation benefits, ensuring that all parties are aware of the implications and the commitments being made.

QuestionAnswer
Form NameForm Libc 14B
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswaiving, CAMERON, HARRISBURG, EMPLOYE

Form Preview Example

LIBC-14B REV 7-02

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS’ COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501

EMPLOYE’S AFFIDAVIT AND WAIVER OF WORKER’S COMPENSATION BENEFITS AND STATEMENT OF RELIGIOUS SECT

(To be filed with the §304.2Application

forReligiousException)

 

EMPLOYE

 

 

 

EMPLOYER

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY/TOWN

STATE

ZIP CODE

 

 

 

 

CITY/TOWN

STATE

ZIP CODE

 

 

 

EMPLOYE SOCIAL SECURITY NUMBER

WAIVER OFWORKERS’COMPENSATIONANDAFFIDAVIT

I, _______________________________ , do hereby state and affirm that I am a member of ______________

EMPLOYE

____________________________________. Its established tenets and/or teachings conscientiously oppose

RELIGIOUS SECT OR DIVISION

member acceptance of any public or private insurance benefits which make payments in the event of death, disability, old age, retirement, or towards the cost of medical bills and provision of services for medical bills (includingthebenefitsofanyinsurancesystemestablishedbytheFederalSocialSecurityAct),andIadheretosaid tenets and/or teachings. I am, therefore, knowingly and voluntarily waiving my rights to any benefits under the PennsylvaniaWorkers’CompensationAct.

Subscribed and affirmed to before me this

_______ day of __________________ , 20 ____

 

 

SIGNATURE OF EMPLOYE

 

 

(OR PARENT OR GUARDIAN IN CASE OF MINOR

 

 

 

NOTARY PUBLIC

(SEAL)

STATEMENTOFRELIGIOUS SECT

I,____________________________________,hereby state and affirm that I am the religious leader of__________

RELIGIOUS SECT LEADER

________________________________ , and I verify that _____________________________ is a current

RELIGIOUS SECTABOVE-NAMED EMPLOYE

member of this sect. I state and affirm that this religious sect has established tenets and/or teachings which oppose its members’ acceptance of any public or private insurance benefits which make payments in the event of death, disability,oldage,retirement,ortowardthecostofmedicalbillsandprovisionofservicesformedicalbills(includ- ing the benefits of any insurance system established by the Federal Social SecurityAct). Furthermore, I state and affirm that it is the practice, and has been for ________ for members of this sect or division to make provision for

NUMBER OF YEARS

their dependent members which, in its judgment, is reasonable in view of their general level of living.

SIGNATURE OF RELIGIOUS SECT LEADER

TITLE

DATE

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2. After filling out this part, go to the subsequent stage and complete all required particulars in all these fields - STATEMENT OF RELIGIOUS SECT, I hereby state and affirm that I, RELIGIOUS SECT LEADER, and I verify that is a current, RELIGIOUS SECT, ABOVENAMED EMPLOYE, member of this sect I state and, their dependent members which in, NUMBER OF YEARS, SIGNATURE OF RELIGIOUS SECT LEADER, TITLE, and DATE.

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