Form 5020 for Pittsburgh Pennsylvania 2025

Form 5020 for Pittsburgh Pennsylvania: What You Should Know

A Proof of Authority must accompany Form DWC-1 to verify the DR application and/or  submit documents to establish you are entitled to workers' compensation benefits for your work-related illness/injury. O Pay Claim Bill on the same date you submit the  DWC-1, OR FURNISH your  Proof of Authority along with the DWC-1  in your DR office within 30 days of filing your Claim of Work-Related Injuries/ Illness. · When submitting your claim, fill out form (WCC-2) and submit to the DR office. O A copy of the “Claim Report” forms (CD 1028, CD 1110, CD 1112), signed and dated, must accompany the  DWI Compensation Waiver as an attachment to  DWI Compensation Waiver — Form 2036. O Provide a complete description of the work-related  INJURY/SICKENING that resulted in your work-related illness/ injury. · Complete and sign and date the “Proof of Injury/ Illness” page on  Form WCC-2 · Complete and sign and date the “Proof of Injury/ Illness” page on the  DWI compensation form (Form 1028) and attach it to your claim o Include the Work Reference Number from the work done and/or injury or illness that you  performed at the time of the injury/illness in the work reference section of your WCC-2. O When completing the “Discharge Information” portion of form (CD 1068 and Form CD 1059), use the complete “Work Reference Number” that appears on your WCC-2 and the DWI Compensation Waiver. NOTE: Do not use a work reference number or an Injury or health number assigned  by the WC PP.  It is a crime for a worker to provide the address of a work address on Form CD 1038 or  CD 1070. · DO NOT provide a work address for a “work-related injury/illness” that was incurred while you were on · DO NOT provide a work address for the work address on the Claim form. DO NOT INCLUDE ANY WORK- REFERENCE NUMBERS.

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