There are many forms that injured workers, employers, and insurers must utilize when a work-related injury occurs in Pennsylvania. All of them are important in their own right and some are more common than others.

The Statement of Wages (LIBC-494) enables the calculation of the correct compensation that may be owed to an injured employee. The form must be completed and submitted within five days after an employer receives notice of any accident that has caused an employee to be disabled for more than the seven-day waiting period required in Pennsylvania.

Form 494A is used for work-related injuries occurring on or before June 23, 1996. Form 494C is used for work-related injuries occurring on or after June 24, 1996. If the employee had more than one employer at the time of injury, a separate Statement of Wages form must be completed for each employer. These forms must then be submitted together.

Once a work-related injury is first reported, within 21 days from the date the employee provides notification of an injury, there are typically four possible outcomes:

  • the employer/carrier denies liability and issues a Notice of Workers’ Compensation Denial (LIBC-496) to the employee. The claim is now closed, though the injured worker can seek legal advice to pursue a claim through the litigation system
  • the employer/carrier issues a Notice of Temporary Compensation Payable (LIBC-501) to extend the investigation period to 90 days before accepting or denying full liability for the injury.
  • the employer/carrier accepts liability for the injury and issues a Notice of Compensation Payable (LIBC-495).
  • the employer/carrier accepts liability for the injury and issues an Agreement for Compensation (LIBC-336).

In the instances where a Notice of Temporary Compensation Payable, Notice of Compensation Payable, or an Agreement for Compensation is issued, all three along with an LIBC-494 Statement of Wages must be filed with the Pennsylvania Bureau of Workers’ Compensation. Employers must use the LIBC-494 to calculate the employee’s wages and should send a copy to the injured employee.

The Statement of Wages must be clearly completed in accordance with the Pennsylvania Workers’ Compensation Act. The “average weekly wage” is used to determine the amount of weekly compensation wage-loss benefits payable under the Pennsylvania Workers’ Compensation Act.  A chart is available from the Bureau of Workers’ Compensation to aid in determining the weekly compensation rate at www.dli.state.pa.us.