PA LIBC-513 2013 free printable template
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EXECUTIVE OFFICER S DECLARATION BUREAU OF WORKERS COMPENSATION INSTRUCTIONS: Each executive officer having an ownership interest in a corporation seeking exemption must complete an original declaration
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How to fill out PA LIBC-513
How to fill out PA LIBC-513
01
Obtain the PA LIBC-513 form from the Pennsylvania Department of Labor & Industry website or your local office.
02
Fill in your personal information, including your name, address, social security number, and contact details.
03
Provide information about your injury or illness, including the date and description of the incident.
04
Indicate your employer's details, including their name and address.
05
Include information about any medical treatment you have received, such as the names of doctors and hospitals.
06
If applicable, explain any wage loss resulting from your injury.
07
Review the completed form for accuracy and completeness.
08
Sign and date the form to certify that the information provided is true.
09
Submit the form to the appropriate address as directed on the form.
Who needs PA LIBC-513?
01
Individuals who have suffered a work-related injury or illness and are seeking workers' compensation benefits in Pennsylvania.
02
Employees who need to file a claim for wage loss or medical expenses due to a workplace incident.
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What is PA LIBC-513?
PA LIBC-513 is a form used in Pennsylvania for reporting information related to wage loss claims for workers' compensation.
Who is required to file PA LIBC-513?
Employers and insurance carriers are required to file PA LIBC-513 when an employee experiences wage loss due to work-related injury or illness.
How to fill out PA LIBC-513?
To fill out PA LIBC-513, provide accurate information regarding the employee's details, employment status, and specifics of the wage loss, including dates and amounts.
What is the purpose of PA LIBC-513?
The purpose of PA LIBC-513 is to document wage loss and ensure appropriate compensation is calculated and administered to employees who sustain injuries on the job.
What information must be reported on PA LIBC-513?
The information that must be reported on PA LIBC-513 includes the employee's name, Social Security number, job title, dates of wage loss, and the amount of wages lost.
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