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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.

Question	Answer
Form Name	Libc 500 Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	libc 500 form, libc 500, libc 500 fillable pdf, fillable libc form

12

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 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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