EMPLOYEE’S AFFIDAVIT AND
WAIVER OF WORKERS’
COMPENSATION BENEFITS AND
BUREAU OF WORKERS’ COMPENSATION
STATEMENT OF RELIGIOUS SECT
(To be filed with the §304.2 Application for Religious Exception)
EMPLOYEE
EMPLOYER
Employer name
First name
Address
Last name
-
-
Address
SS #
City/Town
State
ZIP
Address
FEIN
Address
City/Town
State
ZIP
WAIVER OF WORKERS’ COMPENSATION AND AFFIDAVIT
I,
, do hereby state and affirm that I am a member of
,
EMPLOYEE
RELIGIOUS SECT OR DIVISION
whose established tenets and/or teachings conscientiously oppose member acceptance of any public or private insurance
benefits which make payments in the event of death, disability, old age, retirement, or makes payment towards the cost of or
provides services for medical bills (including the benefits of any insurance system established by the Federal Social Security Act):
I adhere to said tenets and/or teachings. I am, therefore, knowingly and voluntarily waiving my rights to any benefits under the
Pennsylvania Workers’ Compensation Act.
Subscribed and affirmed to before me this
day of
, 20
EMPLOYEE’S SIGNATURE
(or Parent or Guardian in case of minor)
NOTARY PUBLIC
(SEAL)
STATEMENT OF RELIGIOUS SECT
I,
, hereby state and affirm that I am the religious leader of
RELIGIOUS SECT LEADER
,
RELIGIOUS SECT
and I verify that
is a current member of this sect.
ABOVE NAMED EMPLOYEE
I state and affirm that this religious sect has established tenets and/or teachings which oppose its members’ acceptance of
any public or private insurance benefits which make payments in the event of death, disability, old age, retirement, or makes
payments towards the cost of or provides services for medical bills (including the benefits of any insurance system established
by the Federal Social Security Act). Furthermore, I state and affirm that it is the practice, and has been for
NUMBER OF YEARS
for members of the sect or division to make provision for their dependent members which, in its judgment, is reasonable in
view of their general level of living.
RELIGIOUS SECT LEADER’S SIGNATURE
TITLE
RELIGIOUS SECT LEADER’S NAME
DATE
(typed/printed)
(MM-DD-YYYY)
ADDRESS
PHONE NUMBER
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
toll-free inside PA TTY: 800.362.4228
ra-li-bwc-helpline@pa.gov
717.772.3702
local & outside PA: 717.772.4447
local & outside PA TTY: 717.772.4991
*14B*
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-14B REV 04-15