Interested Party Update Request {LIBC-113}

DEPARTMENT OF LABOR & INDUSTRY OFFICE OF ADJUDICATION PENNSYLVANIA WC HEARING - INTERESTED PARTY UPDATE REQUEST Directions: This form is to be used by counsel when there is a discrepancy between the Interested Parties table in WCAIS and the parties that counsel has for a given matter. Prior to the first hearing on the matter, complete this form only for the parties that are incorrect. Enter the correct information exactly as it should appear. Upload the form as a Letter to the Judge on the Documents & Correspondence tab of the Dispute Summary. This form is not to be used for making updates to attorney profile information in WCAIS. * = required field Date* Attorney* Name*: Representing*: PA Bar ID*: ALL FIELDS ABOVE THIS LINE ARE REQUIRED First MI Last WCAIS Claim/DSP/A #* Claimant, insurer or employer Claimant Name: Address: SSN*: Employer Name: Address: FEIN*: Insurer Name: Address: FEIN*: TPA Name: Address: FEIN*: LIBC-113 REV 03-17 (Page 1) First MI Last Street Address City (required for update) State ZIP+4 Self-Insured Street Address City (required for update) State ZIP+4 Street Address City (required for update) State ZIP+4 Street Address City (required for update) State ZIP+4 Healthcare Provider and Healthcare Professional updates may be made on the second page of this form American LegalNet, Inc. www.FormsWorkFlow.com Pennsylvania WC Hearing - Interested Party Update Request Health Care Provider (Organizations, e.g., Hospital) Name: Address: FEIN*: Street Address City (required for update) State ZIP+4 Health Care Professional (Persons, e.g., Doctor) Name: Facility (Provider): Address: Street Address City (required for update) State ZIP+4 Professional License #*: Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-113 REV 03-17 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com