Pennsylvania Required Postings and Forms
Please post the following notices, both in English and Spanish, in a conspicuous location frequented by employees such as the break room, lunch room or time clock. If you have multiple office locations be sure to post the notices at each location.
- Workers’ Compensation Insurance Notice (Form LIBC-500)
- Pennsylvania Worker and Community Right To Know Act (Form LIBC-262) (English and Spanish)
- Anti-Fraud Notice (English and Spanish)
The following document must be signed by the employee at time of hire, whenever changes are made to this document and/or when an on-the-job injury or occupational disease occurs:
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- Form LIBC-344 First Report of Injury (FROI). As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed within 10 days from notice of a work-related injury. Fatalities must be reported within 24 hours. Please use this form to notify EMPLOYERS of every work-related injury or disease suffered by an employee, regardless of severity.
- Form LIBC-494C Wage Statement. This form enables us to calculate the correct compensation that may be owed to your injured employee. Please complete the form and submit it to EMPLOYERS within five days after your knowledge of any accident that has caused your employee to be disabled for more than the Pennsylvania seven day waiting period. If an employee is out of work beyond seven days, the employee may be entitled to indemnity benefits.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 32036, Lakeland, FL 33802-2036. You should also keep a copy on file for your records.
The adjusting of the claims in this state are handled by Broadspire. Once a claim is reported to EMPLOYERS, the report will be sent to Broadspire for assignment.
More Pennsylvania Workers’ Comp Resources
- Off-Site Transitional Duty Program – Helping Your Injured Employees Get Back to Work. A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.