Forms

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The LIBC 500 is an employee notice that is to be printed out and then posted in the workplace. The Workers’ Compensation Employee Notification and the Workers’ Compensation Information Forms are to be initially signed by the employee and then kept by the company in case an injury occurs.

LIBC 500 (English)

Workers’ Compensation Employee Notification (English, Spanish)

Workers’ Compensation Information Form (English, Spanish)

Step # 1: Submit First Report of Injury Form

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The First Report of Injury Form can be submitted online or by fax and is to be completed immediately after an injury occurs (Fatalities must be reported within 8 hours).

To submit online, use our ONLINE First Report of Injury Form. After completion, you will receive a confirmation that your First Report of Injury submission was successful with your claim number.

For paper submission, fax the completed First Report of Injury form to (570) 824-7969, or mail the form to Lackawanna Insurance Group, P.O. Box 6762 Pittsburgh, PA 15212-9998. You will be contacted by a member of our claims department within upon submission.

Step # 2: Complete your Claim Forms

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In addition to submitting the First Report of Injury Form, please have the employee sign the Authorization to Release. Then have the employee re-sign, their Workers' Compensation Employee Notification and Workers' Compensation Information forms that they signed previously before the injury occured.

Authorization to Release (English, Spanish)

Workers’ Compensation Employee Notification (See Information Above)

Workers’ Compensation Information Form (See Information Above)

Fax forms to (570) 824-7969, or send by mail to Lackawanna Insurance Group, P.O. Box 6762 Pittsburgh, PA 15212-9998.

Step # 3: Determine OSHA Reporting Eligibility

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Employers are required to notify OSHA when an employee is killed on the job or suffers a work-related hospitalization, amputation, or loss of an eye. A fatality must be reported within 8 hours and in-patient hospitalization, amputation, or eye loss must be reported within 24 hours. If your incident matches the reporting criteria please proceed to OSHA's Website to notify OSHA.

Designated Provider Panel Program

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The PA Workers’ Compensation Act gives employers the right to establish a list of designated healthcare providers. When the list of designated healthcare providers is properly posted and the employer provides a clearly written notice to employees of their rights and duties, injured workers must seek treatment for a work injury or illness with one of the designated providers for 90 days from the date of the first visit.

As an added benefit to our policyholders, Lackawanna Insurance Group provides the services of Premier Comp Solutions (PCS) to develop functional provider panels. Please contact PCS @ (888) 594-4001 to develop a panel that meets your specific needs. Once a panel is created, PCS can provide appointment scheduling services (24/7), and access to discounted physical therapy and diagnostic services networks.

Pharmacy Program

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Lackawanna Insurance Group has partnered with Optum as our preferred provider of pharmacy benefit management services. Injured employees are automatically enrolled into the program once a claim is submitted and open.

As an added advantage, policyholders can enroll in Optum’s First Fill program that provides injured employees immediate access to medications needed to treat an initial injury, even before a claim is established.

Return to Work Program

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Employers are encouraged to establish a return to work program. By providing modified/restricted duty work employers can reduce workers’ compensation costs, avoid costs of hiring and training a replacement worker, reduce fraud, and promote employee morale. More importantly, it has been recognized that employees have a quicker recovery rate and a better outcome when they continue to work with limitations/restrictions during their healing and recovery period.

The Pennsylvania Department of Labor & Industry Workers Compensation Services provides Pennsylvania employers with the process of establishing Return-to-Work programs; Return-to-Work; A Model for Pennsylvania Business & Industry;