How to File a Petition for Penalties On-Line via the Web:
If the workers' compensation insurance company has not paid workers' compensation benefit checks or medical bills related to treatment of the recognized work injury in a timely manner, or if your workers' compensation check(s) is significantly late, a Petition for Penalties may be filed with the Bureau of Workers' Compensation on line by an attorney or an employee. It is a simple process, but you will need to have all the information in front of you before you begin because, for security reasons, the form will close down if there is a significant time gap in entering the information.
Part 1 Filing a Petition for Penalties form will require the following information:
Employee Social Security number
Date of Injury
PA BWC Claim Number (This is also called a Bureau Claim Number (BCN) and is found on the left side of any hearing notice. If you have a Supplemental Agreement for Payment of Compensation or a Notice of Compensation Payable or Denial, it can be found under the insurer information. If there has been no litigation, you may not have a number, and this space can be left blank.)
Employee Information: a. Name b. Address c. County d. Phone number
Employer Information a. Name b. Address c. County d. Phone number e. The Bureau Code, county, and FEIN number spaces can be left blank if the information is unknown.
Insurer Information a. Name b. Address c. County d. Phone number e. The Bureau Code, county, and FEIN number spaces can be left blank if the information is unknown. (This information can be found on a hearing notice, Notice of Compensation Payable/Denial, or a Supplemental Agreement for Compensation.) f. Claim Number (This is the policy claim number, not the BCN number.)
Description of the injury or cause of death: Put your name in the blank. List the part of the body that was injured and a diagnosis, if you have one. (Example: left elbow/forearm or right shoulder rotator cuff tear) If your condition is an occupational disease, check off that box.
A specific description of what the insurer has failed to pay. (Example: The insurer has failed to pay workers' compensation benefits from (date to date). The insurer has failed to pay for medical treatment for the work injury provided by Dr. _________ for dates of service _______. You have a right to request fifty percent penalties, interest, costs, and attorney fees (if you have an attorney.)
Attorney for the insurance company/employer. Complete the name of the attorney, law firm, address, phone number. These spaces can be left blank if you do not know the information.
The Petitioner (employee or attorney) must enter his name, address, phone number, and date the petition is being filed.
Part 2. Once you have compiled the above information, you are ready to log onto the computer to do the actual filing. Follow these steps:
- Log onto: www.dli.state.pa.us This will take you to the Labor & Industry Home Page. 2. Scroll down this page to the hand x-ray picture towards the bottom right labeled, "Workers' Compensation." Click on this picture. 3. The Bureau of Workers' Compensation page will appear. 4. Click on "Claims Information" in the left column. A "drop down" menu appears. 5. Click on "Petition for Penalties." 6. The Petition for Penalties page will appear. 7. Click on "Petition for Penalties Electronic Submission" in the center of the page. 8. Electronic Filing of Petition for Penalties will appear. Click the Proceed box at the bottom of the page 9. Electronic Filing Log In Page will appear. If you do not have a PA Login Account, click on "Don't have a PA Log in Account?" and complete the application box with your name, address, phone number, e-mail, and choice of user ID word as directed. Hit continue at the bottom. 10. You may now complete the actual form for Petition for Penalties using the information you have prepared in Part 1. 11. When the Petition is completed, click Submit at the bottom of the page. 12. A confirmation page will appear giving you the opportunity to print a copy of your petition. Click on the document to open it, and use the print button at the top left of your screen to print a copy. 13. After you have printed a copy of your petition, you can also save a copy of your petition to a file on your computer. While the document is open, use the save button on the top left of your screen. 14. You may print and save the confirmation page by following the same procedure. Whether or not you choose to print or save a copy of your document, if this page has appeared on your computer, your petition has been received by the Bureau and will be processed and listed for a hearing before a Workers' Compensation Judge. 15. You may close the program. Once you have exited the program, you will not be able to re-open your document on the Bureau website. - 7 - 10