Workers' Compensation Claim Forms

A First Report of Injury (FROI) is required to establish a claim in the Workers' Compensation Automation and Integration System (WCAIS). Forms received by the Bureau of Workers' Compensation prior to submission of the initial FROI transaction cannot be uploaded by the bureau into WCAIS, as there is no claim established in the system to which the form can be attached or filed.

Please remember: For all data and information which is submitted to the department via EDI or upload, a true and correct copy still must be provided to the claimant consistent with the Act, regulations and/or any applicable department-issued policy statement.

More information on electronic filing in WCAIS, including form format, can be found in Section 2.1, "Electronic Data Reporting Format," of the EDI Claims Implementation Guide.

Forms required to be filed with the bureau can be provided in one of several ways: 

• uploading the form to the individual claim's Actions tab (requested method whenever possible);
• utilization of the WCAIS electronic forms generation on the Actions tab to complete submission of the LIBC-494C or to prepare an LIBC-751 for signature and upload;
• submission of an accepted EDI transaction to complete the LIBC-90, LIBC-495, LIBC-496, LIBC-501, & LIBC-502;
• or by sending a hard copy via the US Postal Service. 

The following forms are required to be submitted to the bureau, as submission of the EDI transactions alone does not satisfy the filing requirements under the PA Workers' Compensation Act:

1. LIBC-336 Agreement for Compensation for Disability or Permanent Injury
2. LIBC-337 Supplemental Agreement for Compensation for Disability or Permanent Injury
3. LIBC-338 Agreement for Compensation for Death
4. LIBC-339 Supplemental Agreement for Compensation for Death
5. LIBC-340 Agreement to Stop Weekly Workers' Compensation Payments (Final Receipt)
6. LIBC-380 Third Party Settlement Agreement
7. LIBC-751 Notification of Suspension or Modification
8. LIBC-494C Statement of Wages (For Injuries Occurring On or After June 24, 1996)
9. Marriage Certificate
10.  Death Certificate or Coroners Report
11.  LIBC-764 Notice of Workers' Compensation Disability Status

The forms above are all listed in the upload dropdown on the "Action Tab" of a claim. When one of these document types is selected, it will create an entry in the "Claim History Grid" of the claim to identify that specific form is on the claim. To prevent misinformation, if you wish to upload any other forms to a claim not in this list, they MUST be uploaded to the "Documents and "Correspondence Tab" of the claim. 

NOTE:  When uploading forms to either the "Actions Tab" or the "Documents and Correspondence Tab," each form should be uploaded individually to create an entry in the "Claims History Grid" of a claim for each form's upload.

1. All two-sided forms should be submitted as a single sheet, duplex form (with only one form per upload).
2. Please double-check the accuracy of the information provided, such as employee name, address, and Social Security Number, employer name and address, insurance information, injury date, and description of injury.
3. Signatures are required on some forms. This is a mandatory requirement if requested on the form.
4. Use a medium-point black ink pen on all forms or have them typed.
5. Do not use colored paper.

The following forms are available for download from the Department of Labor & Industry website. These forms will not be filed with the bureau because an EDI transaction satisfies the bureau reporting requirement in the scenarios identified in the PA Claims EDI Release 3 Event Table. However, a copy of the information submitted via the EDI transaction must be sent to the employee/claimant as required by the PA Workers' Compensation Act.

Claim administrators may use LIBC forms currently generated by their system or, for FROI transactions, the LIBC-90 generated by WCAIS. The following forms may also be used and can be downloaded below.

If you are using a single supplemental agreement to report multiple periods, list the most recent period of payment on the front of the form and use the checkbox that matches this event. Subsequent periods of payment may be listed under the "Further matters agreed upon" section on the reverse of the form. Both the claimant's and representative's signatures are required for the form to be considered complete.

Requirements for this form include: 

• You must use the most recent version of the form (2/22).
• You must provide the form to both the claimant and the bureau.
• You must check the two checkboxes to verify service to the parties.
• The form must be provided to the claimant and Bureau within seven days of the suspension or modification effective date.
• The form must indicate whether it is suspending or modifying the claim, and that information must be complete.
• The form must be dated and signed by the claim representative.

Additional notes of importance:

This form cannot be used to stop temporary compensation per Section 121.17(c). 

Please be sure you have submitted your EDI to accept indemnity (Compensable status in WCAIS) prior to suspending or modifying a claim.

An employee signature on the LIBC-751 is only required if the employee is intending to create an employee challenge and request a special hearing regarding the suspension or modification. The employee signature should appear when the employee challenge box is checked.

WCAIS has a screen for the LIBC-751, that will collect the required information and create the form, which must then be printed, signed, and uploaded into WCAIS. A copy of this form must also be sent to the injured worker.

If you are using a single supplemental agreement to report multiple periods, list the most recent period of payment on the front of the form and subsequent periods of payment under "other matters agreed upon" on the reverse of the form. The claimant's signature is required for the form to be considered complete.