Form LIBC-14B at a glance
What it is: This form is the EMPLOYEE'S AFFIDAVIT AND WAIVER OF WORKERS' COMPENSATION BENEFITS AND STATEMENT OF RELIGIOUS SECT.
Where and when to file: File this form with the §304.2 Application for Religious Exception.
A filled-in Form LIBC-14B example: an employee and a sect leader complete the form
How to fill out Form LIBC-14B, box by box
Employee and employer
Under EMPLOYEE, enter the First name, Last name, SS # and Address, City/Town, State and ZIP.
Under EMPLOYER, enter the Employer name, Address, City/Town, State, ZIP and FEIN.
Waiver of workers' compensation and affidavit
In the WAIVER OF WORKERS' COMPENSATION AND AFFIDAVIT, enter the EMPLOYEE after I, and enter the RELIGIOUS SECT OR DIVISION after do hereby state and affirm that I am a member of.
The EMPLOYEE adheres to the established tenets and/or teachings of the RELIGIOUS SECT, which conscientiously oppose member acceptance of any public or private insurance benefits, and is therefore knowingly and voluntarily waiving rights to any benefits under the Pennsylvania Workers' Compensation Act.
The EMPLOYEE'S SIGNATURE (or Parent or Guardian in case of minor) is subscribed and affirmed before a NOTARY PUBLIC (SEAL), with the day of and 20 filled in.
Statement of religious sect
Under STATEMENT OF RELIGIOUS SECT, the RELIGIOUS SECT LEADER enters their name after I, enters the RELIGIOUS SECT after hereby state and affirm that I am the religious leader of, and enters the employee in "ABOVE NAMED EMPLOYEE" who is a current member of this sect.
The RELIGIOUS SECT LEADER enters the NUMBER OF YEARS that it has been the practice for members of the sect or division to make provision for their dependent members, which, in its judgment, is reasonable in view of their general level of living.
Religious sect leader's signature, title, address and phone
The RELIGIOUS SECT LEADER signs the RELIGIOUS SECT LEADER'S SIGNATURE and enters the Religious sect leader's TITLE, the RELIGIOUS SECT LEADER'S NAME (typed/printed), the DATE (MM-DD-YYYY), the Religious sect leader's ADDRESS and the Religious sect leader's PHONE NUMBER.
More rules for Form LIBC-14B
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, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Compliance Division 717.787.3567; Claims Information Services toll-free inside PA: 800.482.2383, local & outside PA: 717.772.4447; Hearing Impaired PA Relay 7-1-1; Email ra-libwc-compliance@pa.gov.
Common questions about Form LIBC-14B
Where do I file it?
File this form with the §304.2 Application for Religious Exception.
Sources
[1] Form LIBC-14B REV 03-25, Employee's Affidavit and Waiver of Workers' Compensation Benefits and Statement of Religious Sect, Pennsylvania Department of Labor & Industry (the Official source link on this page).