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Pennsylvania Form Center

Welcome to the most extensive library of workers' compensation forms available anywhere. Almost 3,000 forms are available for your immediate download and use. Our forms, all of which have been custom programmed by WorkersCompensation.com for Type & Save functionality, are available for individual purchase below.

Try a Forms Membership! If you have an ongoing need for multiple forms, and want complete and unrestricted access to our entire 3,000 "Type & Save" Forms Library, you may register for immediate access here. Annual subscribers to this service get the benefit of our forms updating system, making sure the forms they use are the most current available.

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		*NOTICE!*
		Pennsylvania is a very unique state when it comes to their WC forms. They must be exact and produced with proper format, color reproduction, font size, etc. Forms reproduced incorrectly will not be accepted
		These are Pennsylvania Department of Labor and Industry requirements.
		Instructions for Reproducing Forms. Forms reproduced incorrectly will not be accepted.
		_________________________________________________________________
		(libc-9) Medical Report Form (2 pages), *Duplex Mandatory - 7/04
		(libc-10) Authorization for Alternative Delivery of Compensation Payments (2 pages), *Duplex Mandatory - 6/04
		Instructions for Religious Exception Application - 7/02
		(libc-14a) Application for Religious Exception of Specified Employees from the Provisions of the Pennsylvania Workers' Compensation Act - 1/96
		(libc-14b) Employee's Affidavit and Waiver of Workers' Compensation Benefits and Statement of Religious Sect - 7/02
		(libc-336) OCR FORM - Agreement for Compensation for Disability or Permanent Injury - 11/97
		(libc-337) OCR FORM - Supplemental Agreement for Compensation for Disability or Permanent Injury (2 pages), *Duplex Mandatory - 11/97
		(libc-338) Agreement for Compensation for Death (2 pages), *Duplex Mandatory - 12/97
		(libc-339) Supplemental Agreeement for Compensation for Death (2 pages), *Duplex Mandatory - 12/97
		(libc-340) OCR FORM - Agreement to Stop Weekly Compensation Benefits - 11/97
		(libc-362) OCR FORM - Claim Petition (2 pages), *Duplex Mandatory - 6/08
		(libc-363) Fatal Claim Petition (2 pages), *Duplex Mandatory - 6/04
		(libc-364b) Defendant's Answer to Claim Petition Under Pennsylvania Workers Compensation Occupational disease Act - 11/97
		(libc-374) Defendant's Answer to Claim under Workers' Comp. Act - 5/04
		(libc-375) OCR FORM - Claim Petition for Additional Compensation From the Subsequent Injury Fund (2 pages), *Duplex Mandatory 3/03
		(libc-376) Petition For Joinder of Additional Defendant - 12/97
		(libc-377) Answer to Petition To: 11/04
		(libc-378) OCR FORM - Petition to: (2 pages), *Duplex Mandatory - 11/04
		(libc-380) Third Party Settlement Agreement (2 pages), *Duplex Mandatory - 1/07
		(libc-384) Fatal...Covered by PA Occupational Disease Act (2 pages), *Duplex Mandatory - 4/04
		(libc-386) Fatal...Resulting from Occupational Disease (2 pages), *Duplex Mandatory - 2/05
		(libc-392a) Final Statement of Account of Compensation Paid (2 pages), *Duplex Mandatory - 9/08
		(libc-396) Occupational Disease Claim Petition (under section 301(1) only) (2 pages), *Duplex Mandatory - 3/04
		(libc-480) Subpoena - 9/04
		(libc-494A) Statement of Wages - 12/97
		(libc-494C) OCR FORM - Statement of Wages (for injuries occurring on or after June 24, 1996)(2 pages), *Duplex Mandatory - 8/05
		(libc-495) OCR FORM - Notice of Compensation Payable (NCP) (2 pages), *Duplex Mandatory - 6/04
		(libc-496) OCR FORM - Notice of Workers Compensation Denial (NCD) (2 pages), *Duplex Mandatory - 5/09
		(libc-497) Physicians Afidavit of Recovery - 12/97
		(libc-498) Commutation of Conpensation - 12/97
		(libc-499) Petition for Physical Examination or Expert Interview of Employee - 12/97
		(libc-500) Insurance Posting Form - 6/04
		(libc-501) OCR FORM - Notice of Temporary Compensation - 3/07
		(libc-502) Notice Stopping Temporary Conpensation - 12/97
		(libc-507) OCR FORM - Application for Fee Review Pursuant to Section 306 (F.1) - N/D
		(libc-510) Employer's Application to Elect Domestic Employees to Come Within Provisions of the Workers' Compensation Act: Section 321 - 8/02
		(libc-550) OCR FORM - Claim Petition for Benefits from the Uninsured Employer Guaranty Fund and Uninsured Employer (2 pages), *Duplex Mandatory - 1/07
		(libc-551) OCR FORM - Notice of Claim Against Uninsured Employer (2 pages), *Duplex Mandatory - 1/07
		(libc-601) OCR FORM - Utilization Review Request (Instruction Sheet and Form) (2 pages), *Duplex Mandatory - 9/04
		(libc-603) Review of Utilization Review Determination (2 pages), *Duplex Mandatory - 6/04
		(libc-662) Application for Supersedeas Fund Reimbursement (2 pages), *Duplex Mandatory - 7/07
		(libc-686) Petition for Penalties (2 pages), *Duplex Mandatory - 6/04
		(libc-750) Employee Report of Wages and Physical Condition - 12/97
		(libc-751) OCR FORM - Notice of Suspension or Modification (2 pages), *Duplex Mandatory - 12/06
		(libc-753) Notice of Request for an Informal Conference - 12/97
		(libc-754) Informal Conference Agreement Form - 12/97
		(libc-755) Compromise and Release Agreement - 4/04
		(libc-756) Employees Report of Benefits - 12/97
		(libc-757) Notice of Ability to Return to Work - 5/04
		(libc-758) Notice to Claimant - 8/96
		(libc-760) Employee Verification Of Employment, Self-Employment Or Change In Physical Condition - 3/07
		(libc-761) Notice of Workers Compensation Offset (2 pages), *Duplex Mandatory - 8/01
		(libc-762) Notice of Suspension for Fail to Return Form Libc-760 (2 pages), *Duplex Mandatory - 12/97
		(libc-763) Notice of Reinstatement of Workers Compensation Benefits - 12/97
		(libc-764) Notice of Change of Workers Compensation Disability Benefits (2 pages), *Duplex Mandatory - 12/97
		(libc-765) Impairment Rating Evaluation Appointment (2 pages), *Duplex Mandatory - 12/97
		(libc-766) Request For Designation Of A Physician To Perform An Impairment Rating Evaluation (2 pages), *Duplex Mandatory - 3/08
		(libc-767) Impairment Rating Determination Face Sheet (2 pages), *Duplex Mandatory - 1/07
		(med treatment) Medical Treatment for Your Work Injury or Occupational Illness (2 pages), *Duplex Mandatory - N/D
		Sample Employee Rights and Duties form - NOT A STATE FORM
		Sample Workers Compensation Information form - NOT A STATE FORM

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Pennsylvania Form Center