Pennsylvania Form No. LIBC-500 (Rev 5-09) Workers' Compensation Insurance Posting Poster Required
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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- Original poster PDF https://www.dli.pa.gov/Businesses/Compensation/WC/claims/wcais/Documents/wcais%20forms/LIBC-500%20print.pdf , updated February 2023
- Pennsylvania Labor Law Posters at http://www.dli.pa.gov/Pages/Mandatory-Postings.aspx
- Pennsylvania Department Of Labor & Industry
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