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PA LIBC-513 2018 free printable template

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EXECUTIVE OFFICERSDECLARATIONBUREAU OF WORKERS COMPENSATIONINSTRUCTIONS: Each executive officer having an ownership interest in a corporation seeking exemption must complete an original declaration
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PA LIBC-513 Form Versions

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How to fill out pennsylvania executive officers declaration form

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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
Carefully read the instructions provided with the form to understand what information is required.
03
Fill in your personal information at the top of the form, including your name, address, and contact details.
04
Provide details regarding your employment, including your employer's name, address, and phone number.
05
Describe the nature of your injury or illness, including how it occurred and the date of the incident.
06
Fill out any additional sections as specified in the instructions, including wage information and treatment details.
07
Review the completed form for accuracy and ensure all fields are filled out as required.
08
Sign and date the form before submitting it to the designated office.

Who needs PA LIBC-513?

01
Individuals who have been injured at work in Pennsylvania.
02
Employees who are filing a claim for workers' compensation benefits.
03
Workers seeking to document their injury or illness for the purpose of obtaining financial support.

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Instructions and Help about pa executive officers declaration

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Basic Requirements You must be a U.S. citizen. You must be at least 21 years of age - there is no maximum age. You must have a high school diploma or GED certificate. You must have a valid driver's license. You must have a clean criminal record. You must be in good physical condition.
Act 57 of 2020 is effective July 14, 2021 and requires school entities that employ school police officers (SPO), school resource officers (SRO), and school security guards to retain information about the law enforcement officers and to provide certain information to other prospective law enforcement employers.
Core Values HONOR. We are committed to upholding the Honor of the Force by providing honest and faithful police service to all who may be in danger or distress. SERVICE. We recognize that customer service is our highest priority. INTEGRITY. We believe Integrity is character in action. RESPECT. TRUST. COURAGE. DUTY.
With no compromise for crime and with relentless prosecution of criminals, I will enforce the law courteously and appropriately without fear or favor, malice or ill will, never employing unnecessary force or violence and never accepting gratuities.
I must serve honestly, faithfully, and if need be, lay down my life as others have done before me, rather than swerve from the path of duty. It is my duty to obey the law and to enforce it without any consideration of class, color, creed or condition.
On my honor, I will never Betray my integrity, my character Or the public trust. I will always have the courage to hold myself and others accountable for our actions. I will always maintain the highest ethical standards and uphold the values of my community, and the agency I serve.

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PA LIBC-513 is a form used in Pennsylvania for reporting specific information related to workers' compensation claims.
Employers and insurance companies that are involved in workers' compensation claims in Pennsylvania are required to file PA LIBC-513.
To fill out PA LIBC-513, you need to provide the necessary details about the claim, including the claimant's information, the nature of the injury, and any relevant dates.
The purpose of PA LIBC-513 is to ensure that accurate and complete information is provided regarding workers' compensation claims, facilitating proper processing and record-keeping.
The information that must be reported on PA LIBC-513 includes the claimant's name, address, social security number, details of the injury, date of the incident, and medical treatment received.
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