Supplemental Agreement Form Compensation For Death {LIBC-339}

LIBC-339 -- SUPPLEMENTAL AGREEMENT FOR COMPENSATION FOR DEATH. This form is used by the Pennsylvania Department of Labor & Industry, Bureau of Workers' Compensation when there is a change in the compensation agreement or award due to the death of the dependent of a deceased employee covered under workers' compensation. The form requires information about the deceased employee, including their name, date of birth, date of death, and the nature of the injury. It also requires information about the dependent, including their name, address, and relationship to the deceased. Additionally, the form requires information about the employer and the insurer or third-party administrator, if applicable. The main purpose of this form is to document any changes to the compensation agreement or award following the death of a dependent of a deceased employee covered under workers' compensation. It outlines the revised compensation payable to the dependent and any additional details agreed upon by the parties involved. www.FormsWorkflow.com