Agreement To Stop Weekly Workers Compensation Payments (Final Receipt) {LIBC-340}

LIBC-340 -- AGREEMENT TO STOP WEEKLY WORKERS’ COMPENSATION PAYMENTS FINAL RECEIPT. Signing this form means your weekly workers’ compensation payments will stop. You may file a petition to reopen your claim within three years of the date to which payments were made. SIGN THIS FORM IF: Beginning and ending dates and total amount paid shown below are correct; AND you have fully recovered from your injury or disease. DO NOT SIGN THIS FORM IF: You have returned to work, but are earning less due to work related injury; OR your employer or the insurance company is withholding your last workers’ compensation check unless you sign this form. Agreement should be clearly completed, preferably typed, and uploaded in accordance with the provisions of the EDI Implementation Guide. A copy must be sent to the dependent/guardian/personal representative. Wage information must be completed in accordance with Section 309 of the Pennsylvania Workers’ Compensation Act and sent to the Dependent/Guardian/Personal Representative. www.FormsWorkflow.com