Employers Report Of Injury Or Disease

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EMPLOYEE SOCIAL SECURITY NUMBER
COMMONWEALTH OF PENNSYLVANIA
EMPLOYER’S REPORT
DEPARTMENT OF LABOR AND INDUSTRY
-
-
BUREAU OF WORKERS’ COMPENSATION
OF OCCUPATIONAL
1171 S. CAMERON STREET, ROOM 103
INJURY OR DISEASE
HARRISBURG, PA 17104-2501
DATE OF INJURY
(TOLL FREE) 800-482-2383
TTY (TOLL FREE) 800-362-4228
-
-
MONTH
DAY
YEAR
EMPLOYEE FIRST NAME
EMPLOYEE LAST NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
-
COUNTY
PHONE NUMBER
-
-
EMPLOYEE:
NUMBER OF DEPENDENTS
DATE OF BIRTH
MALE
MARRIED
-
-
FEMALE
SINGLE
MONTH
DAY
YEAR
OCCUPATION OR JOB TITLE
NCCI CLASS CODE (IF KNOWN)
EMPLOYMENT STATUS
FT = Full-time
SL = Seasonal
PT = Part-time
VO = Volunteer
ZZ = Other
EMPLOYER
STREET ADDRESS
CITY
STATE
ZIP CODE
-
SIC CODE
EMPLOYER FEIN
PHONE NUMBER
-
-
-
COUNTY
NAICS CODE
FULL PAY FOR DAY OF INJURY?
TIME EMPLOYEE BEGAN WORK
TIME OF OCCURRENCE
AM
AM
:
YES
:
NO
PM
PM
LAST DAY WORKED
DATE DISABILITY BEGAN
-
-
-
-
MONTH
DAY
YEAR
MONTH
DAY
YEAR
DATE EMPLOYER NOTIFIED
DATE RETURNED TO WORK
DATE OF HIRE
-
-
-
-
-
-
MONTH
DAY
YEAR
MONTH
DAY
YEAR
MONTH
DAY
YEAR
CONTACT FIRST NAME
CONTACT PHONE NUMBER
-
-
CONTACT LAST NAME
NOTICE: Report should be clearly completed, (preferably typed)
and original mailed to the Bureau at the address in the upper left
corner and a copy to employee and insurer.
LIBC-344 REV 1-01
(
)
OVER

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