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Pennsylvania Free Printable Labor Law Posters Posters Pennsylvania Form No. LIBC-500 (Rev 5-09) Workers' Compensation Insurance Posting Poster Required

 Form No. LIBC-500 (Rev 5-09) Workers' Compensation Insurance Posting PDF

The Form No. LIBC-500 (Rev 5-09) Workers' Compensation Insurance Posting is a labor law posters poster by the Pennsylvania Department Of Labor & Industry. This is a mandatory posting for all employers in Pennsylvania, and businesses who fail to comply may be subject to fines or sanctions.

This poster must be posted in a conspicuous place where all employees can see it. This poster is a form for applying for workers' compensation for if a worker is injured while working for an employer.


PA All-In-One Labor Poster: Instead of printing out dozens of posters, employers can also purchase an all-in-one poster that covers both Pennsylvania and Federal poster requirements by clicking here .

LIBC-500 REV 09-22	
REMEMBER: IT IS IMPORTANT TO TELL YOUR 	
EMPLOYER ABOUT YOUR INJURY	
*500*	
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: IF SOMEONE OTHER THAN INSURER IS	 	
(Complete all applicable spaces)	 HANDLING CLAIMS:	
  (Complete all applicable spaces)
Name of Insurance Company:  Name of TPA (Claims administrator):
Address: Address:
Telephone Number:  Telephone Number:
Insurer Code:
IF SELF-INSURED IF SOMEONE OTHER THAN SELF-INSURER IS 	 	
(Complete all applicable spaces)	 HANDLING CLAIMS:	
  (Complete all applicable spaces)
Name of person handling claims at Name of TPA (Claims administrator):
the self-insured:
Address: Address:
Telephone Number:  Telephone Number:
Insurer Code:	
Auxiliary aids and services are available upon request to individuals with disabilities.	
Equal Opportunity Employer/Program	
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of 
the  Pennsylvania  Workers’  Compensation  Act,  77  P.S.  §1039.2,  and  may  also  be  subject  to  criminal  and  civil  penalties  under  18  Pa. 
C.S.A. §4117 (relating to insurance fraud).	 	
Employer Information	
Services	
717.772.3702	
Claims Information Services
toll-free inside PA: 800.482.2383
local & outside PA: 717.772.4447	
Hearing Impaired
PA Relay 7-1-1	
Email	
[email protected]	
DEPARTMENT OF LABOR & INDUSTRYBUREAU OF WORKERS’ COMPENSATION

Other Pennsylvania Labor Law Posters 4 PDFS

There are an additional seventeen optional and mandatory Pennsylvania labor law posters that may be relevant to your business. Be sure to also print all relevant state labor law posters, as well as all mandatory federal labor law posters.


View all 18 Pennsylvania labor law posters


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Instead of printing out pages of mandatory Pennsylvania and Federal labor law posters, you can purchase a professional, laminated all-in-one labor law poster that guarantees compliance with all Pennsylvania and federal posting requirements. Fully updated for 2025!

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Disclaimer:

While we do our best to keep our list of Pennsylvania labor law posters up to date and complete, we cannot be held liable for errors or omissions. Is the poster on this page out-of-date or not working? Please let us know and we will fix it ASAP.

** This Document Provided By LaborPosters.org **
Source: http://www.laborposters.org/pennsylvania/296-workers-compensation-insurance-posting-poster.htm