Defendants Answer To Occupational Disease Claim Petition Section 301(i) Only {LIBC-524}

DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION DEFENDANT222S ANSWER TO OCCUPATIONAL DISEASE CLAIM PETITION SECTION 301(i) ONLY EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER DATE OF INJURY WCAIS CLAIM NUMBER - --- MM DD YYYY EMPLOYEE First name Last name Date of birth Address VS. Commonwealth of Pennsylvania Department of Labor & Industry Address Harrisburg, Pennsylvania City/Town State ZIP County TelephoneTO THE HONORABLE WORKERS222 COMPENSATION JUDGE: Bureau of Workers222 Compensation Address Address Employer Information Claims Information Services Email Services Hearing Impaired *524*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com