Informal Conference Agreement Form {LIBC-754}

DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION INFORMAL CONFERENCE002 AGREEMENT FORM002 EMPLOYEE EMPLOYER INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)1.This matter is currently pending onbefore Workers222 Compensation Judge -- EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - First name Last name Date of birth Address Address City/Town State ZIP County TelephoneDATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY Name Address Address City/Town State ZIP County Telephone FEIN Name Address Address City/Town State ZIP County Telephone FEIN Contact NAIC code or Insurer code Insurer/TPA claim # TYPE OF PETITION(S) NAME ADDRESS MM DD YYYY 402.1 of the Pennsylvania Workers222 Compensation Act. 3.An informal conference was conducted beforeon -- Workers222 Compensation Judge MM DD YYYY At that conference, the employee was was not represented by counsel, and the employer was was not represented by counsel.4.The parties have agreed upon the following matters at the informal conference: American LegalNet, Inc. www.FormsWorkFlow.com If necessary, attach separate pages, each signed by all parties, to state fully the matters agreed upon at the conference. If a002 Notice of Compensation Payable, Agreement for Compensation, or Supplemental Agreement has/have been executed, attach002 Employee222s signature Insurer/Employer222s Agent222s signature Employee222s name (typed/printed)Employee222s Attorney222s signature Employee222s Attorney222s name (typed/printed)Date of this agreement - - MM DD YYYY Insurer/Employer222s Agent222s name (typed/printed)Insurer/Employer222s Attorney222s signature Insurer/Employer222s Attorney222s name (typed/printed) 77 P.S. 2471039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. 2474117 (relating to insurance fraud). Employer Information Services 717.772.3702 Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447 Hearing Impaired Email ra-li-bwc-helpline@pa.gov *754*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com