Pennsylvania Form No. LIBC-500 (Rev 5-09) Workers' Compensation Insurance Posting Poster Mandatory

The Form No. LIBC-500 (Rev 5-09) Workers' Compensation Insurance Posting is a Pennsylvania workers compensation law poster provided for businesses by the Pennsylvania Department Of Labor & Industry. This is a required poster for all Pennsylvania employers, and any business that fails to post this notification may be subject to penalties or fines.

This is a state labor law enforced by state, Pennsylvania Department of Labor and Industry. It is a mandatory posting affecting all workers and employers within the state. The poster provides information what workers and employers should do in the event of an injury on the job or when one develops an occupational disease out of and in the course of the job. The poster highlights workers’ rights as well as the employers’ responsibilities in the event of injury. It describes how to file a claim as a result of an injury and benefits for the injured worker based on the type of injury among other relevant concerns under workers compensation laws. The poster should be correctly posted in a conspicuous place where all employees can see it. Failure to comply with the posting as stated under the law may attract fines and or sanctions.

• Poster PDF
• View Poster Content
• Required for All Workers Compensation Law

LIBC-500 REV 09-22	
REMEMBER: IT IS IMPORTANT TO TELL YOUR 	
EMPLOYER ABOUT YOUR INJURY	
*500*	
The name, address and telephone number of your employer’s workers’ compensation insurance company, third-party 
administrator (TPA), or person handling workers’ compensation claims for your company, are shown below.
Employer Name: Date Posted:
IF INSURED: IF SOMEONE OTHER THAN INSURER IS	 	
(Complete all applicable spaces)	 HANDLING CLAIMS:	
  (Complete all applicable spaces)
Name of Insurance Company:  Name of TPA (Claims administrator):
Address: Address:
Telephone Number:  Telephone Number:
Insurer Code:
IF SELF-INSURED IF SOMEONE OTHER THAN SELF-INSURER IS 	 	
(Complete all applicable spaces)	 HANDLING CLAIMS:	
  (Complete all applicable spaces)
Name of person handling claims at Name of TPA (Claims administrator):
the self-insured:
Address: Address:
Telephone Number:  Telephone Number:
Insurer Code:	
Auxiliary aids and services are available upon request to individuals with disabilities.	
Equal Opportunity Employer/Program	
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of 
the  Pennsylvania  Workers’  Compensation  Act,  77  P.S.  §1039.2,  and  may  also  be  subject  to  criminal  and  civil  penalties  under  18  Pa. 
C.S.A. §4117 (relating to insurance fraud).	 	
Employer Information	
Services	
717.772.3702	
Claims Information Services
toll-free inside PA: 800.482.2383
local & outside PA: 717.772.4447	
Hearing Impaired
PA Relay 7-1-1	
Email	
[email protected]	
DEPARTMENT OF LABOR & INDUSTRYBUREAU OF WORKERS’ COMPENSATION

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More Pennsylvania Labor Law Posters 18 PDFS

Minimum-Wage.org provides an additional seventeen required and optional Pennsylvania labor law posters that may be relevant to your business. Be sure to also print and post all required state labor law posters, as well as all of the mandatory federal labor law posters.

List of all 18 Pennsylvania labor law posters

Pennsylvania Labor Law Poster Sources:

• Original poster PDF URL: https://www.dli.pa.gov/Businesses/Compensation/WC/claims/wcais/Documents/wcais%20forms/LIBC-500%20print.pdf , last updated May 2020
• Pennsylvania Labor Law Poster Page at http://www.dli.pa.gov/Pages/Mandatory-Postings.aspx
• Pennsylvania Department Of Labor & Industry at http://www.dli.pa.gov/