Common Contracts
1 similar Compromise and Release Agreement contracts
PENNSYLVANIA BUREAU OF WORKERS’ COMPENSATIONCompromise and Release Agreement • July 10th, 2013
LIBC-755 FORM ELEMENT NAME DATA ELEMENT NAME DATA # (DN) RECORD IAIABC R3 DICTIONARY (1-1-09)PAGE # HEADING INFORMATION 1 DATE OF INJURY Date of Injury 0031 148; A49 2 PA BWC CLAIM NUMBER (IFKNOWN) Jurisdiction Claim Number 0005 148; A49 EMPLOYEE INFORMATION 3 First Name Employee First Name 0044 148; R22 6-246-26 Last Name Employee Last Name 0043 R21; R22 4 Address Employee Mailing Primary Address 0046 R21 6-25 Address Employee Mailing Secondary Address 0047 R21 6-25 City/Town Employee Mailing City 0048 148 6-25 State Employee Mailing State Code 0049 148 6-25 Zip Employee Mailing Postal Code 0050 148 6-25 County Accident County 0118 R21 6-25 5 Telephone Employee Phone Number 0051 R21 6-26 EMPLOYER INFORMATION 6 Name Employer Name 0018 R21 Address Employer Mailing Primary Address 0168 R21 Address Employer Mailing Secondary Address 0169 R21 City/Town Employer Mailing City 0165 R21 State Employer Mailing State Code 0170 R21 Zip Employer Mailing Postal Code 0167 R
