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    Quick Reference Guide to LIBC Forms - BWC and OCR Forms

    BWC Forms

    Form (LIBC) NumberForm Name

    Program Area

    Format

    WCAIS Usage

    Print
    (P)

    Interactive
    (I)

    Submission
    Method
    (Ledger A)

    Form must be sent to Claimant / Injured Worker
    (Y or N)

    Revised form must be used by this date

    9Workers' Compensation Medical Report Form

    BWC/Healthcare Services

    Web/Fillable

    Online/Mail

    P

    I

    A1, A6

    N

    3/31/2014

     
    10Authorization for Alternative Delivery of Compensation Payments

    BWC/Claims

    Web

    Online/Mail

    P

    I

    N/A

    Yes, if form is used

    6/30/2014

     
    14Instructions for Religious Exception Application

    BWC/Compliance

    Web

    Online/Mail

    P

    N/A

    N/A

    N

    N/A

     
    14AApplication for Religious Exception of Specified Employees from the Provisions of the PA worker's Comp Act

    BWC/Compliance

    Web/Fillable

    Online/Mail

    P

    I

    A1, A4, A6

    N

    N/A

     
    14BEmployee's Affidavit and Waiver of Workers' Compensation Benefits and Statement of religious Sect

    BWC/Compliance

    Web/Fillable

    Online/Mail

    P

    I

    A1, A4, A6

    N

    N/A

     
    20Employers Panel Provider Requirements

    BWC/Healthcare Services

    N/A

    N/A

    P

    N/A

    N/A

    N

    N/A

     
    90Electronic Data Interchange First Report of Injury

    BWC/Claims

    N/A

    Online

    P

    I

    A5

    Y

    N/A

     
    118Application for Benefits Under Section 909 of the Workers’ Compensation Act

    BWC-Self-Insurance

    N/A

    Online/Mail

    P

    N/A

    A6

    N

    N/A

     
    131Qualifications of Reviewer

    BWC/Healthcare Services

    Web

    Online

    P

    I

    A1

    N

    N/A

     
    134Dismemberment Chart

    BWC/Healthcare Services

    Web

    Online/Mail

    P

    I

    N/A

    Yes, if form is used

    N/A

     
    134FDismemberment Chart

    BWC/Healthcare Services

    Web

    Online/Mail

    P

    I

    N/A

    Yes, if form is used

    N/A

     
    210IInsurer’s Annual Report of Accident & Illness Prevention Services

    Health & Safety

    Web

    Online/Mail

    P

    I

    A7

    N

    N/A

     
    211IInsurer’s Initial Report of Accident & Illness Prevention Services

    Health & Safety

    Web

    Online/Mail

    P

    I

    A7

    N

    N/A

     
    220EAnnual Report of Accident & Illness Prevention Program Status by Individual Self-Insured Employers

    Health & Safety

    Web/Fillable

    Online

    P

    I

    N/A

    N

    N/A

     
    221ISelf-Insured Employer's Initial Report of Accident and Illness Prevention Program

    Health & Safety

    Web

    Online/Mail

    P

    I

    A7

    N

    N/A

     
    230GAnnual Report of Accident and Illness Prevention Program Status by Group Self-Insurance Funds

     

     

     

    P

    I

    A7

    N

    6/30/2014

     
    231GInitial Report of Accident and Illness Prevention Program Status by New Group Self-Insurance Funds

     

     

     

    P

    I

    A7

    N

    6/30/2014

     
    336Agreement for Compensation for Disability or Permanent Injury

    BWC/Claims

    Web/Fillable

    Upload

    P

    I

    A1, A2, A6

    Y

    6/30/2014

     
    337Supplemental Agreement for Compensation for Disability or Permanent Injury

    BWC/Claims

    Web/Fillable

    Online/Mail

    P

    I

    A1, A2, A6

    Y

    6/30/2014

     
    338Agreement for Compensation for Death

    BWC/Claims

    Web/Fillable

    Online/Mail

    P

    I

    A1, A2, A6

    Y

    6/30/2014

     
    339Supplemental Agreement for Compensation for Death

    BWC/Claims

    Web/Fillable

    Online/Mail

    P

    I

    A1, A2, A6

    Y

    6/30/2014

     
    340Agreement to Stop Weekly Workers' compensation Payments Final Receipt

    BWC/Claims

    Web/Fillable

    Online/Mail

    P

    I

    A1, A2, A6

    Y

    6/30/2014

     
    350Annual Contribution Worksheet Group Self-Insurance Fund Member Annual Contribution Worksheet Form

    BWC/Self-Insurance

    Web/Fillable

    Upload

    Excel

     

    A7

    N

    9/9/2013

     
    351Expense Loss Cost Multiplier Worksheet for Group Self-Insurance Fund Using Rating Organization Loss Costs Multiplier Calculation Worksheet and Instructions

    BWC/Self-Insurance

    Web/Fillable

    Online

    Sample

     

    A7

    N

    9/9/2013

     
    352Expense Loss Cost Multiplier Worksheet for Group Self-Insurance Fund Deviating From Rating Organization Loss Costs Multiplier Calculation Worksheet and Instructions

    BWC/Self-Insurance

    Web/Fillable

    Online

    Sample

     

    A7

    N

    9/9/2013

     
    365Supplemental Information Addendum to Group Self-Insurance Fund Annual Report

    BWC/Self-Insurance

    Web/Fillable

    Upload

    P

    I

    A7

    N

    9/9/2013

     
    368Supplemental Information Addendum to Application for Membership in a Group Workers' Compensation Fund

    BWC/Self-Insurance

    Web/Fillable

    Upload

    P

    I

    A7

    N

    9/9/2013

     
    369Supplemental Information Addendum to Application as a Group Workers' Compensation Fund

    BWC/  Self-Insurance

    Web/Fillable

    Upload

    P

    I

    A7

    N

    9/9/2013

     
    371Supplemental Information Addendum to Annual Report of Runoff Group Self-Insurance Fund

    BWC/Self-Insurance

    Web/Fillable

    Upload

    P

    I

    A7

    N

    9/9/2013

     
    380Third Party Settlement Agreement

     

     

     

    P

    I

    A1, A2, A6

    Y

    6/30/2014

     
    392AFinal Statement of Account of Compensation Paid

     

     

     

    P

    I

    A5

    Y

    N/A

     
    494AStatement of Wages (For Injuries Occurring On or Before June 23, 1996)

    BWC/Claims

    Web/Fillable

    Upload/Mail

    P

    I

    A1, A2, A6

    Y

    6/30/2014

     
    494CStatement of Wages (For Injuries Occurring On or After June 24, 1996)

    BWC/Claims

    Web/Fillable

    Upload/Mail

    P

    I

    A1, A2, A3, A6

    Y

    6/30/2014

     
    495Notice of Compensation Payable

    BWC/Claims

    PDF

    EDI Generated

    N/A

    N/A

    A5

    N/A

    N/A

     
    495BNotice of Compensation Payable

    BWC/Claims

    PDF

    EDI Generated

    N/A

    N/A

    A5

    N/A

    N/A

     
    496Notice of Workers' Compensation Denial

    BWC/Claims

    PDF

    EDI Generated

    N/A

    N/A

    A5

    N/A

    N/A

     
    498Commutation of Compensation

     

     

     

    P

    I

    A5

    Y

    N/A

     
    500Remember:  It is Important to Tell Your Employer About Your Injury

    BWC/Healthcare Services

    Web

    Online/    Mail

    P

    I

    N/A

    N

    N/A

     
    500(ESP)Recuerde: Es Importante Informarle A Su Empleador Sobre Su Lesion

    BWC/Servicios de atención médica

    Web

    Online/Correo electrónico

    P

    I

    Non Aplicable

    N

    Non Aplicable

     
    501Notice of Temporary Compensation Payable

    BWC/Claims

    PDF

    EDI Generated

    N/A

    N/A

    A5

    N/A

    		N/A
     
    509Application for Executive Officer's Declaration - OCR

    BWC/Compliance

    Web/Fillable

    Online
    Mail

    P

    I

    A1, A4, A6

    N

    6/1/2015

     
    513Executive Officer's Declaration - OCR

    BWC/Compliance

    Web/Fillable

    Upload/Mail

    P

    I

    A1, A4, A6

    N

    9/9/2013

     
    551Notice of Claim Against Uninsured Employer

     

     

     

    P

    		 

     

     

     

     

     
    604Utilization Review Determination Face Sheet

     

     

     

    P

    I

    A1

    Y

    3/31/2014

     
    750Employee Report of Wages

    BWC/Healthcare Services

    Web

    Online/Mail

    P

    I

    N/A

    Yes, if form is used

    6/30/2014

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

    BWC/Claims

    Web/Fillable

    Upload  Mail

    P

    I

    A1, A2, A4, A6

    Y

    2/13/2023

     
    756Employee's Report of Benefits for Offsets

    BWC/Healthcare Services

    Web

    Online/Mail

    P

    I

    N/A

    Yes, if form is used

    6/30/2014

     
    760Employee Verification of Employment, Self-Employment or Change in Physical Condition

    BWC/Healthcare Services

    Web

    Online/Mail

    P

    I

    N/A

    Yes, if form is used

    6/30/2014

     
    761Notice of Workers' Compensation Benefit Offset

     

     

     

    P

    I

    A5

    Y

    6/30/2014

     
    762Notice of Suspension-Failure to Return Form LIBC-760

     

     

     

    P

    I

    A5

    Y

    N/A

     
    763Notice of Reinstatement of Workers' Compensation Benefits

     

     

     

    P

    I

    A5

    Y

    N/A

     
    764Notice of Change of Workers’ Compensation Disability Status (Electronic Data Interchange)

    BWC/Healthcare Services

     Web/Fillable

     Upload/EDI

    P

    I

    A1

    Y

    1/1/2019

     
    765Impairment Rating Evaluation Appointment

    BWC/Healthcare Services

     Web

    Online

    N/A

    N/A

    A3

    Y

    1/1/2019

     
    766Request for Designation of a Physician to Perform an Impairment Rating Evaluation

    BWC/Healthcare Services

    Web

    Online

    N/A

    N/A

    A3

    Y

    1/1/2019

     
    767Impairment Rating Determination Face Sheet

    BWC/Healthcare Services

     Web/Fillable

     Upload/Online

    P

    I

    A1,A4

    Y

    1/1/2019

     
    810Claims Listing Template

    BWC/Self-Insurance

    Excel (download from WCAIS only)

    Upload
    Mail

    Excel

    N/A

    A7

    N

    9/9/2013

     
     Notice: Medical Treatment for Your Work Injury or Occupational Illness

     

     

     

    P

    N/A

    N/A

    Yes, if form is used

    N/A

              

    OCR Forms

    These forms must be completed in black ink with one letter per block.

    507Application for Fee Review Pursuant to Section 306(F.1) - OCR

    BWC/Healthcare Services

    Web/Fillable

    Online
    Mail

    P

    I

    A4, A6

    N

    4/1/2016

     
    601Utilization Review Request

    BWC/UEGF

     

     

     

    Sample

    A4, A6

    Y

    4/1/2016

    Ledger A - Methods available for Bureau Notification

    1) Upload in the WCAIS system by logging in and attaching a document to the claim.

    2) Claim Administrators and Attorneys may log in to WCAIS on the Actions tab to generate an LIBC-494C to submit the form and attach it to the claim in WCAIS.

    3) WCAIS Screen completion, stakeholders can complete the online version of the form in WCAIS and submit the form using the WCAIS system process.

    4) An EDI transaction will be acceptable as bureau notification and no form will need to be sent to the bureau. Adjusters should refer to the PA Implementation Guide for information on which forms this applies.

    5) Hard copy form can be mailed to the Bureau.

    6) Form submitted with the electronic filing of the Self-Insurance Application.

    7) Submission of an accepted EDI transaction to complete the LIBC-495, LIBC-496, LIBC-501 & LIBC-502.