WCOA Forms
| Form (LIBC) Number | Form Name | Program Area | Format | WCAIS Usage | Print (P) | Interactive (I) | Submission Method | Form must be sent to Claimant / Injured Worker (Y or N) | Revised form must be used by this date |
|---|---|---|---|---|---|---|---|---|---|
| 34 | Petition for Commutation | WCOA | Web/Fillable | Upload or mail - no WCAIS screens | Y | 2/2018 | |||
| 35 | Answer to Petition for Commutation |
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| Upload or mail - no WCAIS screens | Y | 6/30/2014 | ||
| 113 | WC Hearing - Interested Party Update Request |
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| Hand deliver to hearing | N/A | N/A | ||
| 362 | Claim Petition for Workers' Compensation |
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| WCAIS screens or mail | N/A | 6/30/2104 | ||
| 363 | Fatal Claim Petition for Compensation by Dependents of Deceased Employees | WCOA | Web/Fillable | Upload Mail | Upload or mail - no WCAIS screens | N/A | 6/30/2014 | ||
| 364B | Defendant's Answer to Claim Petition Under Pennsylvania Occupational Disease Act | WCOA | Web/Fillable | Upload Mail | WCAIS screens or mail | Y | 6/30/2014 | ||
| 374 | Defendant's Answer to Claim Petition under Pennsylvania Workers' Compensation | WCOA | Web/Fillable | Upload/Mail | WCAIS screens or mail | Y | 6/30/2014 | ||
| 375 | Claim Petition or Additional Compensation From the Subsequent Injury Fund Pursuant to Section 306.1 of the Workers' Compensation Act | WCOA | Web/Fillable | Upload/Mail | Upload or mail - no WCAIS screens | N/A | 6/30/2014 | ||
| 376 | Petition for Joinder of Additional Defendant | WCOA | Web/Fillable | Upload/Mail | Upload or mail - no WCAIS screens | Y | 6/30/2014 | ||
| 377 | Answer to Petition To/For | WCOA | Web/Fillable | Upload/Mail | WCAIS screens or mail | Y | 6/30/2014 | ||
| 378 | Petition TO/FOR: (Check any that apply) | WCOA | Web/Fillable | WCAIS screens or mail | Y | 6/30/2014 | |||
| 384 | Fatal Claim Petition for Compensation by Dependents for Death Covered by the Pennsylvania Occupational Disease Act | WCOA | Web/Fillable | Upload | Please contact the BWC Helpline to obtain this form | Please contact the BWC Helpline to obtain this form | Please contact the BWC Helpline to obtain this form. | N/A | 6/30/2014 |
| 386 | Fatal Claim Petition for Compensation by Dependents For Death Resulting From Occupational Disease | WCOA | Web/Fillable | Upload/Mail | Please contact the BWC Helpline to obtain this form | Please contact the BWC Helpline to obtain this form | Please contact the BWC Helpline to obtain this form. | N/A | 6/30/2014 |
| 387 | Important Information About the Petition Filing and Hearing Process | WCOA | Web | N/A | N/A | N/A | N/A | N/A | |
| 396 | Occupational Disease Claim Petition Monthly Compensation for Disability Under Section 301(i) Only | WCOA | Web/Fillable | Upload/Mail | Upload or mail - no WCAIS screens | N/A | 6/30/2014 | ||
| 480 | Subpoena |
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| N/A | WCAIS screens or mail | N/A | N/A | |
| 497 | Physician's Affidavit of Recovery |
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| Upload or mail - no WCAIS screens | Y | 6/30/2014 | ||
| 499 | Petition for Physical Examination or Expert Interview of Employee (Section 314) | WCOA | Web/Fillable | WCAIS screens or mail | Y | 6/30/2014 | |||
| 504 | Child Support Lien Affidavit |
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| Hand deliver to hearing, upload or mail - no WCAIS screens | Y | 2/1/2015 | ||
| 524 | Defendant's Answer to Occupational Disease Claim Petition Section 301(i) Only | WCOA | Web/Fillable | Upload/Mail | WCAIS screens or mail | Y | 6/30/2014 | ||
| 550 | Claim Petition for Benefits from the Uninsured Employer and the Uninsured Employers Guaranty Fund | UEGF/WCOA | Web/Fillable | Online/Mail | WCAIS screens or mail | N/A | 4/2017 | ||
| 551 | Notice of Claim Against Uninsured Employer | UEGF/WCOA | Web/Fillable | Online/Mail | WCAIS screens or mail | N/A | 9/2017 | ||
| 603 | Petition for Review of Utilization Review Determination | WCOA | Web/Fillable | WCAIS screens or mail | Y | 6/30/2014 | |||
| 606 | Request for Hearing to Contest Fee Review Determination | WCOA | Web/Fillable | Upload/Mail | Upload or mail - no WCAIS screens | N | 6/30/2014 | ||
| 749 | Death Claim Supplement to Compromise and Release Agreement |
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| N/A | Upload or mail - no WCAIS screens | N/A | 6/30/2014 | |
| 753 | Notice of Request for an Informal Conference | WCOA | Web/Fillable | Upload/Mail | Upload or mail - no WCAIS screens | Y | 6/30/2014 | ||
| 754 | Informal Conference Agreement Form | WCOA | Web/Fillable | Upload/Mail | N/A | N/A | N/A | ||
| 755 | Compromise and Release Agreement by Stipulation Pursuant to Section 449 of the Workers' Compensation Act | WCOA | Web/Fillable | Upload/Mail | Upload or mail - no WCAIS screens | N/A | 9/2017 | ||
| 757 | Notice of Ability To Return To Work | BWC/Healthcare Services | Web | Online/Mail | Upload or mail - no WCAIS screens | Y | 6/30/2014 | ||
| 758 | Notice to Employee-Note: This form is to be attached to the LIBC-378 |
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| N/A | N/A | Y | N/A | |