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 |
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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, fillable libc 500 forms, pennsylvania 500 form |
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,
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IF SOMEONE OTHER THAN INSURER IS |
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(Complete all applicable spaces) |
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HANDLING CLAIMS: |
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(Complete all applicable spaces) |
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Name of Insurance Company: |
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Name of TPA (Claims administrator): |
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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 |
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Services |
PA Relay |
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717.772.3702 |
local & outside PA: 717.772.4447 |
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*500* |
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program