7 Common Pennsylvania Workers’ Compensation Forms

Pennsylvania workers’ compensation has a form for just about anything you can think of. With so many forms, it can be hard to keep track of what each one is for. To help with that, here are seven of the most common forms you may encounter during your workers’ compensation case. For more information regarding how each form applies to your specific case, contact a workers’ compensation attorney.

Employee Report of Wages and Physical Condition

The Employee Report of Wages and Physical Condition is one of the most important workers’ compensation forms. This form is sent to you by the employer/insurance carrier at most every 6 months. It should be completed and returned to your employer’s insurance company as soon as possible, but no later than 30 days after receipt. Failure to return this completed form can result in your checks stopping.

There are two main things to report on this form: changes in employment and changes in physical condition. If you have obtained new employment or have become self employed, this must be noted on the form. Likewise, if your physical condition regarding your work related injury has changed, this too must be noted. 

It is also a good idea to keep a cover letter with a copy of the forms so you can prove the forms were submitted in a timely fashion. Note, there is another form that looks very similar and can cause confusion. If you are not sure what to do, call my office.

Notice of Workers’ Compensation Denial

Workers' compensation forms judge

If your claim for workers’ compensation is denied by your employer’s insurance company, you should be sent this form within 21 days of the date you provided notice of the accident or injury. The main feature of this form is the inclusion of a reason for the denial. Possible reasons the insurance company may claim are that you:

  • Did not suffer a work related injury of any kind
  • Did not suffer the injury during the scope of your employment
  • Were not an employee of the defendant
  • Have not lost wages due to a previously agreed upon injury
  • Failed to give notice of your injury within 120 days.

If you receive a Notice of Workers’ Compensation Denial it is vital that you speak with a workers’ compensation attorney, or you risk missing your opportunity to receive compensation.

Agreement for Compensation for Disability or Permanent Injury

In some cases, you and your employer will come to an agreement regarding the compensation for your injury. If this is the case, the Agreement for Compensation for Disability or Permanent Injury outlines the terms of the agreement. This form must be signed by both parties and be filed with the Pennsylvania Bureau of Workers’ Compensation. This form can have significant effects on your rights, so it is a good idea not to sign it without having it reviewed first by an experienced Workers’ Compensation attorney.

You should receive a fully executed copy of this form after it is filed with the Bureau and it is a good idea to keep a copy for your records.

Notice of Ability to Return to Work

Medical treatment

The Notice of Ability to Return to Work is a form sent by your employer or your employer’s insurance company if they believe they have medical evidence suggesting that your injuries have healed enough for you to return to work. This is not an order to return to work. Instead, it may be a sign that the insurance company plans to file for a modification or halt to your benefits.

If you do not agree with the conclusions made within the Notice of Ability to Return to Work there are a couple things you should do. Visit your treating physician and ask him/her for their opinion regarding your condition and ability to work. Also, contact your workers’ compensation attorney. Do not feel that you need to return to work just because the insurance company thinks you should.

Notice of Temporary Compensation Payable

A Notice of Temporary Compensation Payable is issued by your employer or their insurance if they do not immediately accept legal responsibility for the injuries you sustained. This form allows them to provisionally accept responsibility for your injury during a 90 day period in which they may further investigate the claim. This acceptance can be for medical treatment only or for medical treatment and wage loss benefits. If the 90 day period passes without the defendants filing to revoke the Notice of Temporary Compensation Payable, it automatically becomes a Notice of Compensation Payable.

If it is properly revoked, it means your claim was never accepted and you have to file a Claim Petition to protect your rights. It is also important to note that the description of injury, average weekly wage, and/or compensation rates may be incorrect on these forms and require correction.

Notice of Compensation Payable

insurance provider

A Notice of Compensation Payable is issued by your employer or their insurance carrier if they accept legal responsibility for your work related injuries. Again, it is important to note that the description of injury, average weekly wage, and/or compensation rates may be incorrect on these forms and require correction.

The Notice of Compensation Payable gives you some significant legal protections, but there are still ways the carrier can legally stop paying you. If you have questions, call a Workers’ Compensation attorney.

Statement of Wages

The Statement of Wages is the workers’ compensation form which is used to calculate your wage loss benefits. The formulas for this calculation can get complicated and confusing. It is usually the insurance carrier that completes this form based on wage information provided by the employer. It is always a good idea to check the accuracy of the underlying wage data and the math to ensure you are being properly paid.

Conclusion

There are a lot of Pennsylvania workers’ compensation forms, but those covered in this article are some of the most common. The Employee Report of Wages and Physical Condition and, in some cases, Statement of Wages forms are those which you submit to your employer. The other five forms on this list come from your employer or their insurance company and are sent to you. If you need help understanding any of these forms or any other forms in relation to your case, contact a workers’ compensation attorney.

Hillsberg Law

My name is Geoffrey Hillsberg and I have concentrated my practice in workers’ compensation law since 1995. If you or someone you know is in need of legal representation, contact Hillsberg Law today. I can help you understand and file all the necessary workers’ compensation forms, negotiate with your employer’s insurance, and represent you in court.