The total ownership interest of all declarations combined must equal 100 percent.
Declaration: the officer declares that they elect not to be an employee of the named corporation for purposes of the Pennsylvania Workers' Compensation Act.
Waiver: the officer declares that they waive any and all benefits and rights which they might be entitled under the Pennsylvania Workers' Compensation Act.
Subchapter S box: check only one box; this one is for an officer who has an ownership interest in a SubchapterS corporation.
Subchapter C box: for an officer who has at least 5 percent ownership interest in a Subchapter C corporation.
Nonprofit box: for an officer who serves voluntarily and without remuneration in a nonprofit corporation.
| Question | Answer |
|---|---|
| Form Name | LIBC-513 |
| Form Length | 1 page |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 3 min |
| Edition | 03-25 |
| Issuing agency | Bureau of Workers' Compensation |
| Who signs | The executive officer |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | LIBC-513, LIBC513, LIBC 513, Form LIBC-513, Pennsylvania LIBC-513, Executive Officer's Declaration |
| Official source | LIBC-513 (Rev 03-25), Pennsylvania Bureau of Workers' Compensation |
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