Spreadsheet: 3fde7dd8-b4e9-449f-b55a-c4d7371396dd
Sheet: Sheet1

BWC Forms
Form (LIBC) Number | Form 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
9 | Workers' Compensation Medical Report Form | BWC/Healthcare Services | Web/Fill able | Online/Mail | P | I | A1, A6 | N | 2014-03-31 00:00:00
10 | Authorization for Alternative Delivery of Compensation Payments | BWC/Claims | Web | Online/Mail | P | I | N/A | Yes, if form is used | 2014-06-30 00:00:00
14 | Instructions for Religious Exception Application | BWC/Compliance | Web | Online/Mail | P | N/A | N/A | N | N/A
14A | Application 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
14B | Employee'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
90 | Electronic Data Interchange First Report of Injury | BWC/Claims | N/A | Online | P | N/A | A5 | Y | N/A
134 | Dismemberment Chart | BWC/Healthcare Services | Web | Online/Mail | P | I | N/A | Yes, if form is used | N/A
134F | Dismemberment Chart | BWC/Healthcare Services | Web | Online/Mail | P | I | N/A | Yes, if form is used | N/A
221I | Self-Insured Employer's Initial Report of Accident and Illness Prevention Program |  |  |  | P | I | A7 | N | 2014-06-30 00:00:00
230G | Annual Report of Accident and Illness Prevention Program Status by Group Self-Insurance Funds |  |  |  | P | I | A7 | N | 2014-06-30 00:00:00
231G | Initial Report of Accident and Illness Prevention Program Status by New Group Self-Insurance Funds |  |  |  | P | I | A7 | N | 2014-06-30 00:00:00
336 | Agreement for Compensation for Disability or Permanent Injury | BWC/Claims | Web/Fillable | Upload | P | I | A1, A2, A6 | Y | 2014-06-30 00:00:00
337 | Supplemental Agreement for Compensation for Disability or Permanent Injury | BWC/Claims | Web/Fillable | Online/Mail | P | I | A1, A2, A6 | Y | 2014-06-30 00:00:00
338 | Agreement for Compensation for Death | BWC/Claims | Web/Fillable | Online/Mail | P | I | A1, A2, A6 | Y | 2014-06-30 00:00:00
339 | Supplemental Agreement for Compensation for Death | BWC/Claims | Web/Fillable | Online/Mail | P | I | A1, A2, A6 | Y | 2014-06-30 00:00:00
340 | Agreement to Stop Weekly Workers' compensation Payments Final Receipt | BWC/Claims | Web/Fillable | Online/Mail | P | I | A1, A2, A6 | Y | 2014-06-30 00:00:00
350 | Annual Contribution Worksheet Group Self-Insurance Fund Member Annual Contribution Worksheet Form | BWC/Self-Insurance | Web/Fillable | Upload | Excel |  | A7 | N | 2013-09-09 00:00:00
351 | Expense Loss Cost Multiplier Worksheet for Group Self-Insurance Fund Using Rating Organization Loss Costs Multiplier Calculation Worksheet and Instructions | BWC/Self-Insurance | Web/Fillable | Upload | Excel |  | A7 | N | 2013-09-09 00:00:00
352 | Expense 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 | Upload | Excel |  | A7 | N | 2013-09-09 00:00:00
365 | Supplemental Information Addendum to Group Self-Insurance Fund Annual Report | BWC/Self-Insurance | Web/Fillable | Upload | P | I | A7 | N | 2013-09-09 00:00:00
368 | Supplemental Information Addendum to Application for Membership in a Group Workers' Compensation Fund | BWC/Self-Insurance | Web/Fillable | Upload | P | I | A7 | N | 2013-09-09 00:00:00
369 | Supplemental Information Addendum to Application as a Group Workers' Compensation Fund | BWC/  Self-Insurance | Web/Fillable | Upload | P | I | A7 | N | 2013-09-09 00:00:00
371 | Supplemental Information Addendum to Annual Report of Runoff Group Self-Insurance Fund | BWC/Self-Insurance | Web/Fillable | Upload | P | I | A7 | N | 2013-09-09 00:00:00
380 | Third Party Settlement Agreement |  |  |  | P | I | A1, A2, A6 | Y | 2014-06-30 00:00:00
392A | Final Statement of Account of Compensation Paid |  |  |  | P | I | A5 | Y | N/A
494A | Statement of Wages (For Injuries Occurring On or Before June 23, 1996) | BWC/Claims | Web/Fillable | Upload/Mail | P | I | A1, A2, A6 | Y | 2014-06-30 00:00:00
494C | Statement of Wages (For Injuries Occurring On or After June 24, 1996) | BWC/Claims | Web/Fillable | Upload/Mail | P | I | A1, A2, [NAME], A6 | Y | 2014-06-30 00:00:00
495 | Notice of Compensation Payable | BWC/Claims | Web/Fillable | Upload/Mail | P | I | A1, A2, [NAME], A6 | Y | 2014-06-30 00:00:00
496 | Notice of Workers' Compensation Denial | BWC/Claims | Web/Fillable | Upload/Mail | P | I | A1, A2, [NAME], A6 | Y | 2014-06-30 00:00:00
498 | Commutation of Compensation |  |  |  | P | I | A5 | Y | N/A
500 | Remember:  It is Important to Tell Your Employer About Your Injury | BWC/Healthcare Services | Web | Online/    Mail | P | N/A | N/A | N | N/A
501 | Notice of Temporary Compensation Payable | BWC/Claims | Web/Fillable | Upload/Mail | P | I | A1, A2, [NAME], A6 | Y | 2014-06-30 00:00:00
502 | Notice Stopping Temporary Compensation | BWC/Claims | Web/Fillable | Online/Mail | P | I | A1, A2, A3, A4, A6 | Y | 2014-06-30 00:00:00
551 | Notice of Claim Against Uninsured Employer | BWC/UEGF | Web/Fillable | Upload/Mail | P | I | A1, A4, A6 | N/A | 2014-06-30 00:00:00
601 | Instructions for Completing Utilization Review Request | BWC/UEGF | Web | Online/  Mail | P | N/A | N/A | N | 2014-03-31 00:00:00
604 | Utilization Review Determination Face Sheet |  |  |  | P | N/A | A1 | Y | 2014-03-31 00:00:00
750 | Employee Report of Wages | BWC/Healthcare Services | Web | Online/Mail | P | I | N/A | Yes, if form is used | 2014-06-30 00:00:00
751 | Notification of Suspension or Modification Pursuant to 413(c) & (d) | BWC/Claims | Web/Fillable | Upload  Mail | P | I | A1, A2, A4, A6 | Y | 2014-06-30 00:00:00
756 | Employee's Report of Benefits for Offsets | BWC/Healthcare Services | Web | Online/Mail | P | I | N/A | Yes, if form is used | 2014-06-30 00:00:00
760 | Employee 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 | 2014-06-30 00:00:00
761 | Notice of Workers' Compensation Benefit Offset |  |  |  | P | I | A5 | Y | 2014-06-30 00:00:00
762 | Notice of Suspension-Failure to Return Form LIBC-760 |  |  |  | P | I | A5 | Y | N/A
763 | Notice of Reinstatement of Workers' Compensation Benefits |  |  |  | P | I | A5 | Y | N/A
764 | Disability Status | BWC/Claims | Web | Online/Mail | P | I | A5 | Y | 2014-06-30 00:00:00
765 | Impairment Rating Evaluation Appointment | WCOA | Web/Fillable | Upload/Mail | P | I | A4, A6 | Y | 2014-03-31 00:00:00
766 | Request for Designation of a Physician to Perform an Impairment Rating Evaluation | BWC/HCSR | Web/Fillable | Upload/Mail | P | I | A4, A6 | Y | 2014-03-31 00:00:00
767 | Impairment Rating Determination Face Sheet | WCOA | Web/Fillable | Upload/Mail | P | I | A1, A6 | Y | 2014-03-31 00:00:00
810 | Claims Listing Template | BWC/Self-Insurance | Excel (download from WCAIS only) | Upload      Mail | Excel | N/A | A7 | N | 2013-09-09 00:00:00
 | Notice: Medical Treatment for Your Work Injury or Occupational Illness |  |  |  | P | N/A | N/A | Yes, if form is used | N/A
OCR Forms
OCR forms must be completed in black ink with one letter per block
507 | Application for Fee Review Pursuant to Section 306(F.1) - OCR | BWC/Healthcare Services | OCR  Web/    Fillable | Online       Mail | P | I | A4, A6 | N | 2014-03-31 00:00:00
509 | Application for Executive Officer's Declaration - OCR | BWC/Compliance | OCR  Web/    Fillable | Online       Mail | P | I | A1, A4, A6 | N | 2013-09-09 00:00:00
513 | Executive Officer's Declaration - OCR | BWC/Compliance | OCR Web/    Fillable | Upload/Mail | P | I | A1, A4, A6 | N | 2013-09-09 00:00:00
601 | Utilization Review Request - OCR | BWC/UEGF | OCR  Web/    Fillable | Online       Mail | P | I | A4, A6 | Y | 2014-03-31 00:00:00
 | Ledger A - Methods available for Bureau Notification
 | 1) Upload in the WCAIS system by logging in and attaching a document to the claim.
 | 2) Submit forms electronically through a batch transmission process. The forms must be submitted one form per file and all files would be submitted to the pre-approved, and assigned  [NAME] folder.
 | 3) Electronic Forms Application: Stakeholders (Insurer, Claim Administrator, Attorney) can log-in to the WCAIS forms application, complete forms LIBC- 494C, LIBC-495, LIBC-496, LIBC-501, LIBC-502, and submit the forms. The form will be attached to the claim in WCAIS.
 | 4) WCAIS Screen completion, stakeholders can complete the online version of the form in WCAIS and submit the form using the WCAIS system process.
 | 5) The EDI transaction will be acceptable as bureau notification. No form will need to be sent to the Bureau.
 | 6) Hard copy form can be mailed to the Bureau.
 | 7) Form submitted with the electronic filing of the Self-Insurance Application.