Libc 500 Form PDF Details

The Libc 500 form is a government document that must be filled out by any business seeking to operate in the United States. It asks for a variety of information about the company, from its ownership and structure to its products and services. Completing the form can be complex, so it's important to consult with an attorney or other professional if you have any questions. Failing to properly complete the Libc 500 form can lead to delays or even refusal of your application. So make sure you take your time and fill out all the required information accurately.

We've collected some basic facts about the libc 500 form. This article will give you specifics of the form's length, finalization duration, and the blanks you may be needed to fill.

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

Form Preview Example

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 iling 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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