Petition For Joinder Of Additional Defendant {LIBC-376}

DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION PETITION FOR JOINDER OF002 ADDITIONAL DEFENDANT002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth If deceased - Dependent/Guardian/Personal Representative First name Last name Address Address City/Town State ZIP County Telephone 223 FUND224 SHALL MEAN THE UNINSURED EMPLOYERS GUARANTY FUND, SUBSEQUENT INJURY FUND, SELF-INSURANCE GUARANTY FUND OR PRE-SELF-INSURANCE GUARANTY FUND. DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYERName Address Address City/Town State ZIP County Telephone FEIN VS. INSURER, FUND or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim # Employee Employer hereby petitions for joinder in connection with the pending petition(s): Additional Employer Additional Insurer Attorney (if known) Name Name Name Address Address Firm name Address Address Address City/Town State ZIP City/Town State ZIP Address County County City/Town State ZIP TelephoneTelephone FEIN TelephoneFEIN NAIC code or Insurer code PA Attorney ID number Additional Employer Additional Insurer Attorney (if known) Name Name Name Address Address Firm name Address Address Address City/Town State ZIP City/Town State ZIP Address County County City/Town State ZIP TelephoneTelephone FEIN TelephoneFEIN NAIC code or Insurer code PA Attorney ID number American LegalNet, Inc. www.FormsWorkFlow.com Additional Employer Additional Insurer Attorney (if known) Name Name Name Address Address Firm name Address Address Address City/Town State ZIP City/Town State ZIP Address County County City/Town State ZIP TelephoneTelephone FEIN Telephone FEIN NAIC code or Insurer code PA Attorney ID number Counsel for Employee Attorney222s name PA Attorney ID number Firm name Address Address City/Town State ZIP Telephone Petitioner or Representative222s signature Petitioner or Representative222s name (typed/printed) Counsel for Employer/Insurer (if known)Attorney222s name PA Attorney ID number Firm name Address Address City/Town State ZIP Telephone - - MM DD YYYY NJoinder is requested for the following reasons: Attached are: Claim and/or other petitions The names/addresses of all parties and their counsel All exhibits taken with dates and locations Services *376*Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com