Guide to PA LIBC Workers’ Compensation Forms

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In Pennsylvania, the Department of Labor & Industry provides a comprehensive set of Workers’ Compensation (WC) forms, known as LIBC forms, to facilitate the management of work-related injuries and illnesses. Understanding and properly using these forms is essential for employers, employees, insurers, and healthcare providers in order to ensure compliance with the Pennsylvania Workers’ Compensation Act.

Key LIBC Forms and Their Purposes:

  1. LIBC-9: Workers’ Compensation Medical Report Form
    • Purpose: Used by healthcare providers to report medical findings related to an employee’s work injury.
    • Access: Available in both printable and interactive formats.
  2. LIBC-336: Supplemental Agreement for Compensation for Disability or Permanent Injury
    • Purpose: Documents any changes in the status of an employee’s disability or compensation.
    • Note: If reporting multiple periods, list the most recent on the front and subsequent periods under “Further matters agreed upon.” Both the claimant’s and representative’s signatures are required.
  3. LIBC-751: Notification of Suspension or Modification Pursuant to Sections 413(c) & (d)
    • Purpose: Notifies employees of the suspension or modification of their benefits because of a return to work.
    • Requirements:
      • Use the most recent version of the form.
      • Provide the form to both the claimant and the Bureau within seven days of the suspension or modification effective date.
      • Indicate whether it is suspending or modifying the claim, and ensure all information is complete.
      • The form must be dated and signed by the claim representative.
    • Additional Notes:
      • This form cannot be used to stop temporary compensation per Section 121.17(c).
      • Ensure submission of your Electronic Data Interchange (EDI) to accept indemnity (Compensable status in WCAIS) prior to suspending or modifying a claim.
      • An employee’s signature is only required if they intend to challenge the suspension or modification.
  4. LIBC-500: Remember: It Is Important to Tell Your Employer About Your Injury
    • Purpose: Informs employees of the importance of reporting work-related injuries promptly.
    • Details: Includes the name, address, and telephone number of the employer’s workers’ compensation insurance company, third-party administrator (TPA), or person handling workers’ compensation claims.
  5. LIBC-100: Workers’ Compensation & the Injured Worker Pamphlet
    • Purpose: Provides a general guide for injured workers on the Pennsylvania Workers’ Compensation Act for work injuries and illnesses occurring on or after June 24, 1996.
    • Content: Includes topics such as insurance coverage, benefits, reporting procedures, and dispute resolution.
  6. LIBC-509: Application for Executive Officer’s Declaration
    • Purpose: Allows certain executive officers to request exclusion from workers’ compensation coverage.
    • Usage: Non-profit corporations may request exclusion for executive officers who serve voluntarily and without remuneration. Subchapter S and C for-profit corporations may request exclusion for executive officers with specific ownership interests.
  7. LIBC-513: Executive Officer’s Declaration
    • Purpose: Formal declaration by an executive officer seeking exclusion from workers’ compensation coverage.
    • Submission: Must be filed with the employer’s insurance carrier if the employer has a policy covering other employees, or with the Bureau of Workers’ Compensation if the employer has no other employees.

Accessing and Submitting LIBC Forms:

Most LIBC forms are available in both printable (P) and interactive (I) online formats. Submission methods vary and may include uploading through the Workers’ Compensation Automation and Integration System (WCAIS), mailing to the Bureau of Workers’ Compensation, or providing directly to the claimant. It’s crucial to use the most recent version of each form and adhere to the specified submission guidelines to ensure compliance.

For a comprehensive list of LIBC forms and detailed instructions, please visit the Pennsylvania Department of Labor & Industry’s official website.

pa.gov

Understanding and properly utilizing these forms will assist all parties involved in workers’ compensation matter in navigating the workers’ compensation process effectively and ensure timely and accurate handling of claims.