Legal Forms for Employees Seeking Workers’ Compensation in Pennsylvania

Helping Injured Workers Through the Complex Process of Claiming Benefits

If you have sustained an injury while in the court of your job duties, the Pennsylvania Workers’ Compensation Act allows you to collect benefits while you recover. There is a tremendous amount of paperwork and documentation that goes into making a successful claim for benefits, which is why you should always work with an experienced workers’ compensation attorney when you file your claim or seek an appeal.

Below you will find links to some of the more common documentation for making a claim. If you are self-insured, there are additional materials and steps you will take, and you should contact our firm immediately to find out what your rights are.

If you wish to file a claim for workers’ compensation in Pennsylvania, the Department of Labor & Industry recommends you read the following information:

Common Legal Forms Used in Claims for Workers’ Compensation in Pennsylvania

All titles and links come directly from the Pennsylvania Department of Labor & Industry. Some links are for informational purposes only, and cannot be printed and filled out.

LIBC 9    Medical Report Form

LIBC 10    Authorization for Alternative Delivery of Compensation Payments

LIBC 25/26    Appeal from Judge’s Findings of Fact and Conclusions of Law

LIBC 34    Petition for Commutation

LIBC 90    Electronic Data Interchange First Report of Injury

LIBC 337    Supplemental Agreement for Compensation for Disability or Permanent Injury

LIBC 338    Agreement for Compensation for Death

LIBC 339    Supplemental Agreement for Compensation for Death

LIBC 362    Claim Petition for Workers’ Compensation

LIBC 363    Fatal Claim Petition for Compensation by Dependents of Deceased Employees

LIBC 375    Claim Petition for Additional Compensation From the Subsequent Injury Fund

LIBC 376    Petition for Joinder of Additional Defendant

LIBC 377    Answer to Petition To/For

LIBC 378    Petition TO/FOR: (Check any that apply)

LIBC 380    Third Party Settlement Agreement

LIBC 392A    Final Statement of Account of Compensation Paid

LIBC 396    Occupational Disease Claim Petition Monthly Compensation for Disability Under Section 301(i) Only

LIBC 480    Subpoena

LIBC 495    Notice of Compensation Payable

LIBC 496    Notice of Workers’ Compensation Denial

LIBC 497    Physician’s Affidavit of Recovery

LIBC 499    Petition for Physical Examination or Expert Interview of Employee (Section 314)

LIBC 501    Notice of Temporary Compensation Payable

LIBC 502    Notice Stopping Temporary Compensation

LIBC 504    Child Support Lien Affidavit

LIBC 550    Claim Petition for Benefits from the Uninsured Employer and the Uninsured Employers Guaranty Fund

LIBC 551    Notice of Claim Against Uninsured Employer

LIBC 552    Authorization to Release Information/Verification or Information

LIBC 604    Utilization Review Determination Face Sheet

LIBC 749    Death Claim Supplement to Compromise and Release Agreement

LIBC 750    Employee Report of Wages

LIBC 751    Notification of Suspension or Modification Pursuant to 413(c) & (d)

LIBC 753    Notice of Request for an Informal Conference

LIBC 754    Informal Conference Agreement Form

LIBC 755    Compromise and Release Agreement by Stipulation Pursuant to Section 449 of the Workers’ Compensation Act

LIBC 757    Notice of Ability To Return To Work

LIBC 761    Notice of Workers’ Compensation Benefit Offset

LIBC 763    Notice of Reinstatement of Workers’ Compensation Benefits

Hurt at Work? Let Us Help You

Larry Pitt & Associates is the Philadelphia workers’ compensation law firm you can trust. We’ve been helping your friends and neighbors recover after a worksite injury for close to 40 years. If you or your family member was hurt on the job, we will fight on your behalf. To schedule your free consultation with one of our Philadelphia workers’ compensation attorneys, please call 1-888-PITT-LAW or fill out our contact form. We proudly represent clients in Bucks County, Berks County, Chester County, Delaware County, Montgomery County and Philadelphia County.

Testimonials

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Larry Pitt's team is very professional. I am 110% happy with the outcome of mt case.

 

Melissa Yonkers

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5.0
2019-01-18T13:32:01+00:00

Melissa Yonkers

Larry Pitt's team is very professional. I am 110% happy with the outcome of mt case.  

“Very Professional”

Answered or returned calls and emails in a timely fashion. The employees at this firm are working for us the employee, not the employers. Very professional.

Anna Diaz

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5.0
2019-01-15T14:51:34+00:00

Anna Diaz

Answered or returned calls and emails in a timely fashion. The employees at this firm are working for us the employee, not the employers. Very professional.

“They Go Above and Beyond”

The staff of Larry Pitt & Associates cannot be more helpful when going through a tremendously tough time. They are there for you and have answers for you before you even ask. They go above and beyond and are always on top of their game. Their time, consideration and professionalism are more than anyone can ask for. Highly recommend them and their services they provide!

Terri Delaney

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5.0
2018-12-10T13:17:05+00:00

Terri Delaney

The staff of Larry Pitt & Associates cannot be more helpful when going through a tremendously tough time. They are there for you and have answers for you before you even ask. They go above and beyond and are always on top of their game. Their time, consideration and professionalism are more than anyone can ask for. Highly recommend them and their services they provide!

“Best Worker’s Compensation Law Firm in Pennsylvania”

If you're in need of a Worker's Compensation lawyer, do not doubt that Larry Pitt and Associates is the Best Worker's Compensation Law Firm in Pennsylvania

Ryan Hoffman

hreview
5.0
2018-11-16T18:57:03+00:00

Ryan Hoffman

If you're in need of a Worker's Compensation lawyer, do not doubt that Larry Pitt and Associates is the Best Worker's Compensation Law Firm in Pennsylvania

A friend recommended Larry Pitt and associates to me after being hurt at work.

A friend recommended Larry Pitt and associates to me after being hurt at work. They were incredibly compassionate and handled my case professionally with an outstanding outcome.

D.R., client

hreview
5.0
2018-11-16T16:12:21+00:00

D.R., client

A friend recommended Larry Pitt and associates to me after being hurt at work. They were incredibly compassionate and handled my case professionally with an outstanding outcome.

“Thank you for being so professional..”

"Thank you for being so professional in the way you and your staff handles my case. I am a little late showing my appreciation, but thank you so much. If I ever need someone to represent me again, you would be the ones!"

Annette P. Walls

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5.0
2018-11-16T15:51:00+00:00

Annette P. Walls

"Thank you for being so professional in the way you and your staff handles my case. I am a little late showing my appreciation, but thank you so much. If I ever need someone to represent me again, you would be the ones!"

“I want to thank you for your excellent representation”

"I want to thank you for your excellent representation of me and keeping your word. You asked me to hold on and things would be resolved in the Spring, and they were. Ariana’s graduation was beautiful and I was able to give her everything I wanted, including her class ring.

Also and not forgotten, Luba! She was so patient and attentive to me even when I was hysterical. Ha! Ha!"

Dierdre P.

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5.0
2018-11-16T15:49:51+00:00

Dierdre P.

"I want to thank you for your excellent representation of me and keeping your word. You asked me to hold on and things would be resolved in the Spring, and they were. Ariana’s graduation was beautiful and I was able to give her everything I wanted, including her class ring. Also and not forgotten, Luba! She was so patient and attentive to me even when I was hysterical. Ha! Ha!"

“Thank you so much for hearing my cry for help!”

"Thank you so much for hearing my cry for help! You have always been there and I feel very comfortable with this Firm. It is wonderful people like you that makes me feel so Proud of Larry Pitt & Associates. Once again Thank You!"

John Rodriguez

hreview
5.0
2018-11-16T15:49:08+00:00

John Rodriguez

"Thank you so much for hearing my cry for help! You have always been there and I feel very comfortable with this Firm. It is wonderful people like you that makes me feel so Proud of Larry Pitt & Associates. Once again Thank You!"

“I want to thank you for representing me and for everything you guys have done for me.”

"I want to thank you for representing me and for everything you guys have done for me. I am extremely happy with the outcome-especially since my boss didn't show up at the final hearing. Thanks for your patience and understanding and most of all-compassion. I truly appreciate all your help."

Jennifer Kitz

hreview
5.0
2018-11-16T15:48:34+00:00

Jennifer Kitz

"I want to thank you for representing me and for everything you guys have done for me. I am extremely happy with the outcome-especially since my boss didn't show up at the final hearing. Thanks for your patience and understanding and most of all-compassion. I truly appreciate all your help."

“Life is much more than business. But, business is about relationships..”

"Peace & blessings to you, sir. With a lot of prayers for you and your family. Life is much more than business. But, business is about relationships. Mr. Pitt, I honor ours. Please sir, let’s keep in touch from time to time."

Salin Muhammed

hreview
5.0
2018-11-16T15:46:15+00:00

Salin Muhammed

"Peace & blessings to you, sir. With a lot of prayers for you and your family. Life is much more than business. But, business is about relationships. Mr. Pitt, I honor ours. Please sir, let’s keep in touch from time to time."
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