Libc 500 Form PDF Details

Within the landscape of workers' compensation, the LIBC-500 form plays a pivotal role, serving as the cornerstone for initiating claims related to workplace injuries. This document, provided by the Department of Labor & Industry Bureau of Workers’ Compensation, emphasizes the critical step of informing one's employer about any injury incurred on the job. It outlines the necessary information to be filled regarding the employer's workers' compensation insurance company, third-party administrator (TPA), or the designated individual handling such claims. The form is meticulously structured to accommodate different scenarios, whether the employer is insured, self-insured, or if the claims are managed by a TPA. Apart from the contact details of the insurance company or claims administrator, this form serves as a stern reminder about the legal repercussions of submitting misleading or false information, underlining the serious nature of insurance fraud and its penalties. Moreover, it stands as a resource not only for workers navigating through the claims process but also ensures that help is readily available through various channels, acknowledging the importance of accessibility for all individuals, including those with disabilities.

QuestionAnswer
Form NameLibc 500 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslibc 500 form, libc 500, libc 500 fillable pdf, fillable libc form

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DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION

REMEMBER: IT IS IMPORTANT

TO TELL YOUR EMPLOYER

ABOUT YOUR INJURY

The name, address and telephone number of your employer’s workers’ compensation insurance company, third-party administrator (TPA), or person handling workers’ compensation claims for your company, are shown below.

Employer Name:

 

Date Posted:

 

 

IF INSURED:

IF SOMEONE OTHER THAN INSURER IS

 

(Complete all applicable spaces)

HANDLING CLAIMS:

 

 

 

 

 

(Complete all applicable spaces)

 

Name of Insurance Company:

Name of TPA (Claims administrator):

 

Address:

Address:

 

Telephone Number:

 

Telephone Number:

 

 

Insurer Code:

 

 

 

 

 

 

 

 

 

 

 

 

IF SELF-INSURED

IF SOMEONE OTHER THAN SELF-INSURER IS

(Complete all applicable spaces)

HANDLING CLAIMS:

 

 

 

(Complete all applicable spaces)

Name of person handling claims at

Name of TPA (Claims administrator):

the self-insured:

 

 

Address:

Address:

Telephone Number:

 

Telephone Number:

 

Insurer Code:

 

 

 

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).

Employer Information

Claims Information Services

Hearing Impaired

Email

Services

toll-free inside PA: 800.482.2383

PA Relay 7-1-1

ra-li-bwc-helpline@pa.gov

717.772.3702

local & outside PA: 717.772.4447

 

 

 

 

 

*500*

Auxiliary aids and services are available upon request to individuals with disabilities.

Equal Opportunity Employer/Program

LIBC-500 REV 04-18

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Type in the necessary details in Name of person handling claims at, Name of TPA Claims administrator, the selfinsured, Address, Address, Telephone Number, Telephone Number, Insurer Code, Any individual filing misleading, Employer Information Services, Claims Information Services, Hearing Impaired PA Relay, Auxiliary aids and services are, and Email ralibwchelplinepagov box.

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