Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act.
Employee signature: employee's signature (or Parent or Guardian in case of minor).
Religious sect leader: the Statement of Religious Sect has the religious sect leader's signature, title, name (typed/printed), date, address and phone number.
Compliance Division: 717.787.3567.
Auxiliary aids: auxiliary aids and services are available upon request to individuals with disabilities.
| Question | Answer |
|---|---|
| Form Name | LIBC-14B |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 25 |
| Avg. time to fill out | 5 min |
| Edition | 03-25 |
| Filed with | §304.2 Application for Religious Exception |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | LIBC-14B, LIBC14B, LIBC 14B, Form 14B, 14B form, Pennsylvania LIBC-14B, Employee's Affidavit and Waiver of Workers' Compensation Benefits and Statement of Religious Sect |
| Official source | LIBC-14B (Rev 03-25), |
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