Commutation Of Compensation {LIBC-498}

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION COMMUTATION OF002 COMPENSATION002 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 Address City/Town State ZIP County Telephone DATE OF THIS NOTICE:EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP -- County MM DD YYYY Telephone FEIN NAIC code or Insurer code Insurer/TPA claim #A copy of this notice of Commutation of Compensation is to be sent to the employee with full payment of compensation commuted. Pursuant to Section 412 of the Pennsylvania Workers222 Compensation Act, future installments of compensation payable to the above employee not being in excess of 52 weeks, the employer/insurer indicated above hereby advises the above employee of its intent to immediately pay in one sum such future installments without discount. Compensation for this injury, , is presently payable under002 NATURE OF INJURY Notice of Compensation Payable or Agreement for weeks days. Compensation paid to date of this notice: weeks days. Compensation due in future: weeks days @ $per week for a total of $ to be paid in one sum without discount. Employer Authorized Agent for Insurer or TPA (if self-insured) First name Last name Signature First name Last name Signature Employer Information Claims Information Services Email Services Hearing Impaired *498* Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com