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

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