Workers Compensation Insurance
Workers Compensation Claim Form
Choose from our covered physicians - View the "Physicians Panels" by District
Claims are handled by our Third Party Administrator:
PO Box 3899
2 North Second St
Harrisburg, PA 17101
Kim Piper – extension 4040
How to report a claim:
- Complete the Workers Compensation Claim Form – Employer’s Report of Occupational Injury or Disease.
Be sure to include all information especially the Employer Federal Identification Number on the form
- Forward completed form and a copy of the latest W-2 or pay stub for the injured employee to the Finance Office – email firstname.lastname@example.org.
- Once your claim has been submitted, you will be provided with a claim number for your medical provider to use in their billing process. Your church should have a Physicians Panel for your county; you may go to any of those for the first 90 days. After that you may go to your own provider.
- If immediate medical attention is needed before your claim number is available, give your provider the Third Party Administrator information listed above and your Social Security Number for claim payments. You must still complete and submit the Workers Compensation Claim Form as described in steps 1 & 2.
- For additional assistance, please direct all questions to Rev. Jason Mackey - email@example.com or call 717-766-5275.
Workers Compensation Insurance Information
Department of Labor Employer's Certificate of Insurance Requests
When your participating church or daycare receives a request for LIBC-661, simply complete the form as shown and return it along with a copy of our Proof of Coverage Permit.