Form Libc 344 PDF Details

The Libc 344 form carries crucial significance within the Commonwealth of Pennsylvania, administered by the Department of Labor and Industry's Bureau of Workers' Compensation. This form is a foundational document that employers must complete and submit following an employee's occupational injury or disease report. Detailed sections of the Libc 344 demand comprehensive information, ranging from basic employee identification, such as name and social security number, to more intricate details pertaining to the injury or illness itself—this includes specifics like the date and nature of the injury, parts of the body affected, and the cause. Additionally, the form delves into whether the injury occurred on the employer's premises, usage of safety equipment, and details surrounding the incident's occurrence. It does not stop at recording incidents but extends to include information on the initial medical treatment provided and details concerning the healthcare provider. Significantly, the form acts as a legal document, urging accuracy in presenting facts to mitigate any potential for fraudulent claims. There exists a stern warning against the submission of misleading or incomplete information, emphasizing the form's role in maintaining the integrity of the compensation process. Clearly outlined are also instructions for the distribution of the completed form—originally mailed to the Bureau and copies to be furnished to the employee and insurer—ensuring transparency and acknowledgment from all involved parties. The Libc 344, therefore, is not just a formality but a critical step in ensuring that incidents of occupational injuries or diseases are reported ethically and processed efficiently, underpinning the worker's compensation system in Pennsylvania.

QuestionAnswer
Form NameForm Libc 344
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespennsylvania libc disease, pennsylvania report occupational, libc 344, pa libc 344

Form Preview Example

COMMONWEALTH OF PENNSYLVANIA

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

(TOLL FREE) 800-482-2383

TTY (TOLL FREE) 800-362-4228

EMPLOYEE FIRST NAME

EMPLOYER’S REPORT

EMPLOYEE SOCIAL SECURITY NUMBER

 

 

 

-

 

 

 

-

 

 

 

 

 

OF OCCUPATIONAL

 

 

 

 

 

 

 

 

 

 

 

INJURY OR DISEASE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF INJURY

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MONTH

 

 

DAY

 

 

 

 

YEAR

EMPLOYEE LAST NAME

STREET ADDRESS

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COUNTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE NUMBER

 

 

 

 

 

 

 

-

-

EMPLOYEE:

 

MALE

MARRIED

FEMALE

SINGLE

OCCUPATION OR JOB TITLE

NUMBER OF DEPENDENTS

DATE OF BIRTH

-

MONTHDAY

-

YEAR

NCCI CLASS CODE (IF KNOWN)

EMPLOYMENT STATUS

FT = Full-time

SL = Seasonal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PT = Part-time

VO = Volunteer

 

 

 

 

 

 

 

 

 

 

ZZ = Other

EMPLOYER

STREET ADDRESS

CITY

STATE

ZIP CODE

SIC CODE

EMPLOYER FEIN

PHONE NUMBER

-

-

COUNTY

FULL PAY FOR DAY OF INJURY?

TIME EMPLOYEE BEGAN WORK

YES

 

 

 

:

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

PM

-

NAICS CODE

TIME OF OCCURRENCE

:

 

 

AM

 

 

PM

 

 

 

-

LAST DAY WORKED

DATE DISABILITY BEGAN

 

 

-

 

 

-

 

 

 

 

MONTH

 

DAY

 

 

YEAR

DATE EMPLOYER NOTIFIED

-

MONTHDAY

DATE RETURNED TO WORK

-

YEAR

DATE OF HIRE

-

MONTHDAY

CONTACT FIRST NAME

-

YEAR

-

MONTH

-

DAY

YEAR

CONTACT PHONE NUMBER

-

-

MONTHDAY

-

-

YEAR

CONTACT LAST NAME

NOTICE: Report should be clearly completed, (preferably typed) and original mailed to the Bureau at the address in the upper left corner and a copy to employee and insurer.

LIBC-344 REV 1-01

(OVER)

LIBC 344

TYPE OF INJURY CODE

 

PART OF BODY AFFECTED CODE

CAUSE OF INJURY CODE (ENTER CODES, IF KNOWN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF INJURY OR ILLNESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PARTS OF BODY AFFECTED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAUSE OF INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DID INJURY OR ILLNESS OCCUR

 

IF OUT OF STATE, SPECIFY

WERE SAFEGUARDS OR SAFETY

 

WERE SAFEGUARDS OR SAFETY

ON EMPLOYER’S PREMISES?

 

STATE OF INJURY

EQUIPMENT PROVIDED?

 

EQUIPMENT USED?

YES

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

NO

ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES DIRECTLY RESPONSIBLE.

IF FATAL, GIVE DATE OF DEATH

 

 

 

-

 

 

 

-

 

 

 

 

 

 

MONTH

DAY

 

 

YEAR

 

PHYSICIAN/HEALTH CARE PROVIDER

 

FIRST NAME:

 

 

 

 

 

 

LAST NAME:

 

STREET

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOSPITAL NAME:

 

 

 

 

 

 

 

 

 

STREET

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICY/SELF INSURED NUMBER:

INITIAL TREATMENT:

NO MEDICAL TREATMENT

MINOR BY EMPLOYEE

CLINIC / HOSPITAL

PANEL PHYSICIAN

EMPLOYEE PHYSICIAN

EMERGENCY CARE

HOSPITALIZED MORE THAN 24 HOURS

POLICY PERIOD FROM:

 

 

 

 

 

 

 

-

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

MONTH

 

DAY

 

 

YEAR

POLICY PERIOD TO:

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

MONTH

 

DAY

 

 

YEAR

WITNESS FIRST NAME

WITNESS PHONE NUMBER

-

-

WITNESS LAST NAME

PERSON COMPLETING THIS FORM:

NAME:

TITLE:

PHONE:

DATE PREPARED

INSURANCE CARRIER OR THIRD PARTY ADMINISTRATOR (IF SELF-INSURED)

NAME:

STREET

 

 

CITY

STATE

ZIP

 

BUREAU CODE:

FEIN:

 

-

MONTH

-

DAYYEAR

Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165.

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