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Get Libc 500 Rev 5 09 Form

772. 0621 www. dli. state. pa.us LIBC-500 REV 5-09 221-8805 1/12 Auxiliary aids and services are available upon request to individuals with disabilities. CLEAR PRINT REMEMBER It is Important to Tell Your Employer about Your Injury The name address and telephone number of your employer s workers compensation insurance company third-party administrator TPA or person handling workers compensation claims for your company are shown below. Employer Name Date Posted IF INSURED Complete all applicable spaces IF SOMEONE OTHER THAN INSURER IS HANDLING CLAIMS Name of Insurance Company Name of TPA Claims administrator Address Telephone Number Insurer s Bureau Code IF SELF-INSURED Name of person handling claims at the self-insured Self-Insured Bureau Code Department of Labor Industry Bureau of Workers Compensation 1171 S* Cameron Street Room 103 Harrisburg PA 17104-2501 717. CLEAR PRINT REMEMBER It is Important to Tell Your Employer about Your Injury The name address and telephone number of your employer s workers compensation insurance company third-party administrator TPA or person handling workers compensation claims for your company are shown below. Employer Name Date Posted IF INSURED Complete all applicable spaces IF SOMEONE OTHER THAN INSURER IS HANDLING CLAIMS Name of Insurance Company Name of TPA Claims administrator Address Telephone Number Insurer s Bureau Code IF SELF-INSURED Name of person handling claims at the self-insured Self-Insured Bureau Code Department of Labor Industry Bureau of Workers Compensation 1171 S* Cameron Street Room 103 Harrisburg PA 17104-2501 717.

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