PENNSYLVANIA STATUTES TITLE 77. WORKERS COMPENSATION CHAPTER 12. UNINSURED EMPLOYERS GUARANTY FUND GO TO CODE ARCHIVE DIRECTORY FOR THIS JURISDICTION

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1 PENNSYLVANIA STATUTES TITLE 77. WORKERS COMPENSATION CHAPTER 12. UNINSURED EMPLOYERS GUARANTY FUND GO TO CODE ARCHIVE DIRECTORY FOR THIS JURISDICTION 77 P.S (2006) Definitions The following words and phrases when used in this article shall have the meanings given to them in this section unless the context clearly indicates otherwise: COMPENSATION. Benefits paid pursuant to sections 306 and 307 EMPLOYER. Any employer as defined in section 103 The term does not include a person that qualifies as a self-insured employer under section 305 FUND. The Uninsured Employers Guaranty Fund established in section 1602 The fund shall not be considered an insurer and shall not be subject to penalties, unreasonable contest fees or any reporting and liability requirements under section 440 POLICYHOLDER. A holder of a workers compensation policy issued by the State Workers Insurance Fund, or an insurer that is a domestic, foreign or alien mutual association or stock company writing workers compensation insurance on risks which would be covered by this act. SECRETARY. The Secretary of Labor and Industry of the Commonwealth. History: Act (H.B. 2738), 7, approved v. 9, 2006, eff. in 60 days Fund (a) ESTABLISHMENT. -- (1) There is established a special fund to be known as the Uninsured Employers Guaranty Fund. (2) The fund shall be maintained as a separate fund in the State Treasury subject to the procedures and provisions set forth in this article. (b) SOURCE. -- The sources of the fund are: (1) Assessments provided for under section 1607 (2) Reimbursements or restitution. (3) Interest on money in the fund.

2 (c) USE. -- The administrator shall establish and maintain the fund for the exclusive purpose of paying to any claimant or his dependents workers compensation benefits due and payable under this act and the act of June 21, 1939 (P.L. 566,. 284), known as The Pennsylvania Occupational Disease Act, and any costs specifically associated therewith where the employer liable for the payments failed to insure or self-insure its workers compensation liability under section 305 at the time the injuries took place. (d) ADMINISTRATION. -- The secretary shall be the administrator of the fund and shall have the power to collect money for and disburse money from the fund. (e) STATUS. -- The fund shall have all of the same rights, duties, responsibilities and obligations as an insurer. History: Act (H.B. 2738), 7, approved v. 9, 2006, eff. in 60 days Claims (a) SCOPE. -- This section shall apply to claims for an injury or a death which occurs on or after the effective date of this article. (b) TIME. -- An injured worker shall notify the fund within 45 days after the worker knew that the employer was uninsured. The department shall have adequate time to monitor the claim and shall determine the obligations of the employer. compensation shall be paid from the fund until notice is given and the department determines that the employer failed to voluntarily accept and pay the claim or subsequently defaulted on payments of compensation. compensation shall be due until notice is given. (c) PROCESS. -- After notice, the fund shall process the claim in accordance with the provisions of this act. (d) PETITIONS. -- claim petition may be filed against the fund until at least 21 days after notice of the claim is made to the fund. History: Act (H.B. 2738), 7, approved v. 9, 2006, eff. in 60 days Claim petition If a claim for compensation is filed under this article and the claim is not voluntarily accepted as compensable, the employee may file a claim petition naming both the employer and the fund as defendants. Failure of the uninsured employer to answer a claim petition shall not serve as an admission or otherwise bind the fund under section 416 History: Act (H.B. 2738), 7, approved. 9, 2006, eff. in 60 days.

3 2705. Department (a) INSURANCE INQUIRY. -- Within ten days of notice of a claim, the fund shall demand from the employer proof of applicable insurance coverage. Within 14 days from the date of the fund s request, the employer must provide proof of insurance. If the employer does not provide proof, there shall be rebuttable presumption of uninsurance. (b) REIMBURSEMENT. -- The department shall, on behalf of the fund, exhaust all remedies at law against the uninsured employer in order to collect the amount of a voluntary payment or award, including voluntary payment or award itself and reimbursement of costs, interest, penalties, fees under section 440 and costs of the fund s attorney, which have been paid by the fund. The fund shall also be reimbursed for costs or attorney fees which are incurred in seeking reimbursement under this subsection. The department is authorized to investigate violations of section 305 for prosecution of the uninsured employer pursuant to section 305 (b) and shall pursue such prosecutions through coordination with the appropriate prosecuting authority. Any restitution obtained shall be paid to the fund. (c) BANKRUPTCY. -- The department has the right to appear and represent the fund as a creditor in a bankruptcy proceeding involving the uninsured employer. (d) LIENS. -- If payments of any nature have been made by the fund on behalf of an uninsured employer, the fund shall file a certified proof of payment with the prothonotary of a court of common pleas, and the prothonotary shall enter the entire balance as a judgment against the employer. The judgment shall be a statutory lien against property of the employer in the manner set forth in section of the act of December 5, 1936 (2nd Sp.Sess., 1937 P.L. 2897,. 1), known as the Unemployment Compensation Law, and execution may issue on it. The fund has the right to update the amount of the lien as payments are made. History: Act (H.B. 2738), 7, approved v. 9, 2006, eff. in 60 days Other remedies thing contained in this article shall serve to abrogate the provisions of section 305(d) allowing the claimant or dependents to bring a direct suit for damages at law as provided by Article II. The fund shall be entitled to assert rights to subrogation under section 319 for recovery made from the employer or any other third party. History: Act (H.B. 2738), 7, approved v. 9, 2006, eff. in 60 days.

4 2707. Assessments For the purpose of establishing and maintaining the fund, the sum of $ 1,000,000 is hereby transferred from the Administration Fund established under section 446 to the fund for operation of the fund for the period commencing on the effective date of this section through June 30, The department shall calculate the amount necessary to maintain the fund and shall assess insurers and self-insured employers as is necessary to provide an amount sufficient to pay outstanding and anticipated claims in the following year in a timely manner and to meet the costs of the department to administer the fund. The fund shall be maintained in the same manner as the Workmen s Compensation Administration Fund under section 446 and the regulations thereunder. In no event shall any annual assessment exceed 0.1% of the total compensation paid by all insurers or self-insured employers during the previous calendar year. History: Act (H.B. 2738), 7, approved v. 9, 2006, eff. in 60 days Regulations The department may promulgate regulations for the administration and enforcement of this article. History: Act (H.B. 2738), 7, approved v. 9, 2006, eff. in 60 days.

5 PA Bulletin, Doc Page 1 of 4 STATEMENTS OF POLICY Title 34--LABOR AND INDUSTRY DEPARTMENT OF LABOR AND INDUSTRY [34 PA. CODE CH. 123] Uninsured Employer Guaranty Fund [37 Pa.B. 317] [Saturday, January 20, 2007] The Department of Labor and Industry (Department), Bureau of Workers' Compensation, adds Chapter 123, Subchapter I (relating to Uninsured Employer Guaranty Fund--statement of policy) to read as set forth in Annex A. This statement of policy provides guidance regarding Article XVI of the Workers' Compensation Act (act) (77 P. S. -- ), as amended by the act of vember 9, 2006 (P. L. 1362,. 147) (Act 147). Article XVI of the act, as amended by Act 147, became effective January 8, A. Effective Date This statement of policy will be effective upon publication in the Pennsylvania Bulletin. B. Contact Person Interested parties may obtain further information and provide comments regarding this statement of policy by writing to John T. Kupchinsky, Director, Bureau of Workers' Compensation, P. O. Box 15121, Harrisburg, PA This statement of policy will also be available on the Department's website at C. Statutory Authority This statement of policy is issued under the authority of section 435 of the act (77 P. S. 991), which authorizes the Department to adopt regulations that are reasonably calculated to explain and enforce the provisions of the act. Section 435 of the act charges the Department with promulgating rules and regulations that are reasonably calculated to expedite the reporting and processing of injury cases; insure full payment of compensation when due; expedite the hearing and determination of claims for compensation; and provide notice to disabled employees of their rights under the act. In addition, section 1608 of the act (77 P. S. ), as amended by Act 147, specifically authorizes the Department to promulgate regulations for the administration and enforcement of Article XVI of the act. 9/14/2009

6 PA Bulletin, Doc Page 2 of 4 D. Purpose On vember 9, 2006, Governor Edward G. Rendell signed Act 147 into law. Pertinently, Act 147 added Article XVI to the act. Article XVI establishes and funds the Uninsured Employer Guaranty Fund (Fund), which provides benefits to injured employees of uninsured employers. Article XVI of the act requires that an injured worker notify the Fund within 45 days after the injured worker knew that the employer was uninsured. Further, Act 147 prohibits an injured worker from filing a claim petition against the Fund until at least 21 days after notice of a claim is made to the Fund. This statement of policy does not constitute a rule or regulation with the force and effect of law. This statement of policy is issued so that all parties will have a clear understanding of their rights and obligations under Article XVI of the act. The Department intends to promulgate regulations for this purpose as soon as practical. STEPHEN M. SCHMERIN, Secretary (Editor's te: Title 34 of the Pa. Code is amended by adding a statement of policy in to read as set forth in Annex A.) Fiscal te: fiscal impact; (8) recommends adoption. Sec. Annex A TITLE 34. LABOR AND INDUSTRY PART VIII. BUREAU OF WORKERS' COMPENSATION CHAPTER 123. GENERAL PROVISIONS--PART II Subchapter I. UNINSURED EMPLOYER GUARANTY FUND-- STATEMENT OF POLICY Uninsured Employer Guaranty Fund tice to the Uninsured Employer Guaranty Fund Prerequisites for filing claim petition for benefits from Fund Filing of claim petition for benefits from the Fund Rights of Fund Uninsured Employer Guaranty Fund. The Department of Labor and Industry (Department) adopts this statement of policy so that all parties will have a clear understanding of their rights and obligations under the act, as amended by Act 147 of 2006 (P. L. 1362,. 147) (Act 147). This subchapter does not constitute a rule or regulation with the force and effect of law. The Department intends to promulgate regulations for this purpose as soon as practicable. 9/14/2009

7 PA Bulletin, Doc Page 3 of tice to the Uninsured Employer Guaranty Fund. (a) For purposes of Article XVI of the act (77 P. S. -- ), an injured worker who seeks benefits from the Uninsured Employer Guaranty Fund (Fund) shall notify the Fund of a claim within 45 days from the date upon which the injured worker knew that the employer was uninsured. (b) Compensation will not be paid from the Fund until notice is given. (c) tice to the Fund shall consist of completing and mailing the form designated as ''tice of Claim Against Uninsured Employer'' (tice) to the Department of Labor and Industry (Department) at the address listed on the form. The Department may reject any incomplete tice. (d) The tice will be deemed filed as of the date of the tice's deposit in the United States Mail, as evidenced by a United States Postal Service postmark, properly addressed, with postage or charges prepaid. If a United States Postal Service Postmark is not present, the date of the Department's actual receipt of the tice is the filing date Prerequisites for filing claim petition for benefits from Fund. (a) Upon the filing of a completed ''tice of Claim Against Uninsured Employer'' (tice), the Uninsured Employer Guaranty Fund (Fund) will determine whether it will commence making payments. (b) An injured worker may not seek an award against the Fund unless the worker completes and files the form designated as the ''Claim Petition for Benefits from the Uninsured Employer Guaranty Fund.'' (c) A ''Claim Petition for Benefits from the Uninsured Employer Guaranty Fund'' may not be filed until at least 21 days after the injured worker filed the tice as required in (relating to notice to the Uninsured Employer Guaranty Fund). (d) A completed ''Claim Petition for Benefits from the Uninsured Employer Guaranty Fund'' will be deemed filed upon the later of either of the following: (1) The date of the petition's deposit in the United States Mail, as evidenced by a United States Postal Service postmark, properly addressed, with postage or charges prepaid; or, if no United States Postal Service Postmark is present, as of the Department's receipt of the petition. (2) Twenty-one days after the filing of the tice identified in (e) The Department may reject any incomplete petition Filing of claim petition for benefits from the Fund. 9/14/2009

8 PA Bulletin, Doc Page 4 of 4 (a) If an injured worker attempts to file a ''Claim Petition for Benefits from the Uninsured Employer Guaranty Fund'' before filing the ''tice of Claim Against Uninsured Employer'' (tice) required under (relating to notice to the Uninsured Employer Guaranty Fund), the Department will return the petition to the injured worker and instruct the worker to complete a tice. (b) A Claim Petition for Workers' Compensation (LIBC--362) filed against an employer may not act as a claim against the Uninsured Employer Guaranty Fund (Fund) or be deemed notice to the Fund. (c) An injured worker seeking an award of benefits from the Fund shall file the ''Claim Petition for Benefits from the Uninsured Employer Guaranty Fund'' with the Bureau and shall serve the Fund and the alleged employer at the addresses identified on the petition. The Fund is not required to answer a petition which does not conform to this section Rights of Fund. The Uninsured Employer Guaranty Fund (Fund) is not prejudiced by an agreement, admission or stipulation concerning the compensability, facts or legal conclusions relating to an injury underlying a claim against the Fund unless the Fund is a party to and specifically endorses the agreement, admission or stipulation. [Pa.B. Doc Filed for public inspection January 19, 2007, 9:00 a.m.] part of the information on this site may be reproduced for profit or sold for profit. This material has been drawn directly from the official Pennsylvania Bulletin full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version. webmaster@pabulletin.com 9/14/2009

9 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA (TOLL FREE) TTY NOTICE OF CLAIM AGAINST UNINSURED EMPLOYER EMPLOYEE SOCIAL SECURITY NUMBER DATE OF INJURY Instructions: Please complete both sides of this form and mail to the address listed above. You must also forward a copy to the Pennsylvania Uninsured Employer Guaranty Fund at P.O. Box 1774, Harrisburg, PA You must complete all questions that appear in bold print, or the Bureau will not accept this form and will return to you. You may file a Claim Petition for Benefits from the Uninsured Employer Guaranty Fund and Uninsured Employer, Form LIBC-550, at least 21 days after filing this form. EMPLOYEE EMPLOYER Name Name Address Address City/Town State Zip City/Town State Zip County Telephone ( ) County Telephone ( ) FEIN Date of Birth Owner/Contact I am the injured employee. I am the injured employee s dependent, and I am seeking benefits relating to a fatal injury. INJURY Did the injury occur in the course of employment with the Employer identified above? Was the injury reported to the Employer? If, when? Describe the incident and injury. DISABILITY Occupation/Job Title Did the employee sign a contract of employment with the Employer identified above? Last Day Worked Hours worked per week List the employee s wages $ per hour / day / week (circle one) Attach most recent pay stub. Did the injury cause a loss of wages? Has the employer been paying for lost wages? Has the employee returned to work? How much is the employee earning? $ per hour / day / week (circle one) For whom does the employee work? Give name, address and telephone number. MEDICAL Has the employee sought medical treatment for the work injury? Has the employer paid for medical treatment for the work injury? LIBC (Page 1) (OVER)

10 List Doctors/Medical Facility and their addresses. (Attach additional sheets, if necessary.) The injured employee (or dependent, if the employee is deceased) must complete and sign the following authorization, which the Uninsured Employer Guaranty Fund may use to collect records relating to medical treatment that the injured or deceased employee received, and to collect wage information from the injured or deceased employee s current or previous employer(s). AUTHORIZATION TO RELEASE INFORMATION / VERIFICATION OF INFORMATION To Whom It May Concern: By signing below, I hereby request and authorize you to furnish, to the Pennsylvania Uninsured Employer Guaranty Fund or its representative(s), any and all information you have concerning the above-named employee with respect to any illness or injury, medical history, consultation, treatment, including x-rays, as well as copies of all hospital or medical records, military records or other government records. I further request and authorize employers to furnish complete information concerning wages, commissions, and the like. By signing below, I attest that I am the employee identified above, or that I am the deceased employee s dependent authorized to request the release of such records, and that I am pursuing a claim for benefits under the Pennsylvania Workers Compensation Act. A photocopy of this authorization shall be considered as effective and valid as the original authorization. VERIFICATION By signing below, I verify that all information submitted on this form is, to the best of my knowledge, information and belief, true, complete and correct. I understand that any individual who knowingly and with the intent to defraud, files misleading or incomplete information, is in violation of Section 1102 of the Pennsylvania Workers Compensation Act, and may also be subject to civil and criminal penalties, including prosecutions under 18 Pa. C.S.A (relating to False Swearing). Signed: Dated Print Name: Address: Phone: Relationship to deceased employee, if applicable: LIBC (Page 2) Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program

11 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA (TOLL FREE) TTY CLAIM PETITION FOR BENEFITS FROM THE UNINSURED EMPLOYER GUARANTY FUND AND UNINSURED EMPLOYER EMPLOYEE SOCIAL SECURITY NUMBER DATE OF INJURY PA BWC CLAIM NUMBER (IF KNOWN) EMPLOYEE First Name Last Name EMPLOYER Name Address If Deceased - Dependent or Guardian First Name Last Name Address Address City/Town State County Telephone ( ) Zip Address City/Town State Zip VS. County Telephone ( ) FEIN AND Pennsylvania Uninsured Employer Guaranty Fund P.O. Box 1774 Harrisburg, PA Employees should file this Petition if they are seeking an award against the Uninsured Employer Guaranty Fund because their employer did not maintain workers compensation insurance coverage and was not approved as a self-insurer at the time of the alleged injury. NOTE: You may not file this petition until at least 21 days after you filed a tice of Claim Against Uninsured Employer, Form LIBC Have you filed a tice of Claim Against Uninsured Employer, Form LIBC-551? 2. Complete description of injury or illness including all parts of body affected. 3. If occupational disease, give the last date of employment and/or last date of exposure 4. Give date of injury or onset of disease 5. How did the injury or disease occur? 6. Did injury or disease occur on employer s premises? Where? (Be specific.) 7. tice of your injury or disease was served on your employer on in the following manner: 8. What was your job title at the time of injury or disease? LIBC (Page 1) (OVER)

12 9. Were you working for more than one employer at the time of your injury? If, list additional employers: 10. Did this problem cause you to stop working? If, give date. 11. Are you back to work with the same employer? If, Regular Job Other Job / Give Title. 12. Are you working with another employer? If, give name and address of new employer: 13. What were your wages at the time of injury? $ Hour Day or Week 14. If you have returned to work since your injury or illness, are you earning. More Same Less than you were at the time of injury? Current earnings $. Hour Day or Week 15. I am seeking payment for (check all that apply): Loss of Wages Partial disability from to Full disability from to Medical bills (give name of doctor/hospital, address, type of treatment and bill in space below). Counsel fees to be paid by the employer. (te: The Fund is not subject to unreasonable contest attorney fees.) Loss or loss of use of arm, hand, finger, leg, foot or toe. Disfigurement (scars) of head, face, or neck. Injury or disease resulting in death. Date of death. Loss of sight. Loss of hearing. 16. Have you filed any other Workers Compensation Petition(s) related to this injury? If, PA BWC Claim Number (if known) PLEASE ENTER MYAPPEARANCE FOR PETITIONER: Attorney Name PA Attorney ID# Name of Firm Address Address City/Town State Zip Telephone ( ) DATE OF PETITION A copy of this petition has been sent to the employer and the Fund. Signature Employee Attorney NOTICE: This Petition must be filled out as fully as possible. The original must be sent to the Bureau of Workers Compensation, 1171 South Cameron Street, Room 103, Harrisburg, PA You must send a copy of this Petition to the employer and Guaranty Fund, P.O. Box 1774, Harrisburg, PA Information on the completion of this from may be obtained by calling the Bureau of Workers Compensation Helpline at Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165. LIBC (Page 2) Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program

13 Has Insurance (717) , Ext. 619 September 16, 2009 Prefix First Name Middle Initial. Last Name, Suffix Company Name Address 1 City, State Zip Code Re: Claimant v. Employer Dear Prefix Last Name: Thank you for informing the Bureau of Workers Compensation (Bureau) of this matter. Based in part upon the information provided in your Date of Letter tice of Claim against Uninsured Employer (tice) the Bureau s Compliance Section has conducted an investigation into Name of Employer workers compensation insurance coverage. This investigation has revealed that Name of Insurer issued a workers compensation policy to Name of Employer effective Start Date through End Date. This policy period covers the date of injury alleged in the tice. Please note that the Uninsured Employer Guaranty Fund is not liable for payment of workers compensation benefits covered by a workers compensation insurance policy. Any claim you believe you/your client have/has should be directed toward this insurer. Very truly yours, John T. Kupchinsky Director, Bureau of Workers Compensation JTK/ck cc: Claimant Employer Thomas Kuzma, Deputy Chief Counsel, Legal Division John Strawser, Manager, Compliance Section

14 Self-Insured (717) , Ext. 619 September 16, 2009 Prefix First Name Middle Initial. Last Name, Suffix Company Name Address 1 City, State Zip Code Re: Claimant v. Employer Dear Prefix Last Name : Thank you for informing the Bureau of Workers Compensation (Bureau) of this matter. Based in part upon the information provided in your Date of Letter tice of Claim against Uninsured Employer (tice) the Bureau s Compliance Section has conducted an investigation into Name of Employer s workers compensation insurance coverage. This investigation has revealed that Name of Employer has been an approved selfinsured employer since Start Date of SI. Their current period of self-insurance expires on Renewal Date. The period of self-insurance covers the date of injury alleged in the tice. Please note that the Uninsured Employer Guaranty Fund is not liable for payment of workers compensation benefits covered by a workers compensation insurance policy or which arises from an injury in employment with a self-insured employer. Any claim you believe you/your client have/has should be directed toward this self-insured employer. Very truly yours, John T. Kupchinsky Director, Bureau of Workers Compensation JTK/ck cc: Claimant Employer

15 Predate Letter (717) , Ext. 619 September 16, 2009 Prefix First Name Middle Initial. Last Name, Suffix Company Name Address 1 City, State Zip Code Re: Claimant v. Employer Dear Prefix Last Name : Thank you for informing the Bureau of Workers Compensation (Bureau) of this potential criminal matter. Based in part upon the information provided in your Date of Letter tice of Claim against Uninsured Employer (tice) the Bureau s Compliance Section has begun an investigation into Name of Employer workers compensation insurance coverage. A Compliance Section investigator may contact you for additional information. With respect to your client s workers compensation benefits, please note that the Uninsured Employer Guaranty Fund (UEGF) provides benefits solely for claims on injuries incurred on or after January 8, Your tice indicates that this matter relates to an injury allegedly incurred on Injury Date and, therefore, does not fit within the statutorily-prescribed period for the receipt of UEGF benefits. However, your client may receive restitution or other payments from the employer as a result of the Bureau s investigation and potential criminal prosecution of this matter. Thank you again for alerting us to this matter. Very truly yours, John T. Kupchinsky Director, Bureau of Workers Compensation JTK/ck cc: Thomas Kuzma, Deputy Chief Counsel, Legal Division John Strawser, Manager, Compliance Section

16 Lien Letter (717) , Ext. 619 September 16, 2009 Prefix First Name Middle Initial. Last Name, Suffix Company Name Address 1 City, State Zip Code Re: Claimant v. Employer Dear Prefix Last Name : Claimant (claimant) has filed a tice of Claim against Uninsured Employer (LIBC-551) (tice) under the Workers Compensation Act (Act). The tice alleges that the claimant was injured in the scope of employment with you or your company, and that you or your company failed to maintain a workers compensation insurance policy covering the alleged date of injury. A preliminary analysis reveals that you or your company did not maintain workers compensation insurance, as required by law, when the claimant suffered the alleged injury. Please immediately respond to this office, in writing, to inform the Uninsured Employer Guaranty Fund (UEGF) whether you intend to make payment to the claimant for this alleged injury. If you fail to pay or fail to actively participate in the litigation of this claim, the UEGF may pay compensation to the claimant. You must reimburse the UEGF for all compensation that it pays on your behalf, and for all costs associated with paying this claim, including attorneys fees and the cost of recovering these sums from you. If the UEGF pays compensation to the claimant without your active participation, this will be the only notice that you receive. If you fail to reimburse the UEGF, it may enter a judgment and lien(s) against you or your company in the amount of all moneys paid on the claim, as well as for all costs, interest, penalties, fees and attorneys fees and costs of collection, as provided in section 1605 of the Act, 77 P.S The UEGF is obligated to pursue collection of all amounts that it pays on your or your company s behalf, and may do so to the fullest extent permitted by law. Very truly yours, JTK/ck John T. Kupchinsky Director, Bureau of Workers Compensation

17 Declined (717) , Ext. 619 September 16, 2009 Prefix First Name Middle Initial. Last Name, Suffix Company Name Address 1 City, State Zip Code Re: Claimant v. Employer Dear Prefix Last Name : The Department s Uninsured Employer Guaranty Fund (Fund) is in receipt of the tice of Claim against Uninsured Employer (tice) that you filed on Date of Letter. The Fund has investigated the matter described in the tice, but declines to voluntarily accept liability for any alleged injury, and thus will not make payment in this matter. Should you wish to pursue this matter through litigation, you may do so by completing and filing the enclosed Claim Petition for Benefits from the Uninsured Employer Guaranty Fund and Uninsured Employer. Please be advised if your claim results in the payment of benefits from the Fund, and you also receive payment from a third party lawsuit arising from the same work injury, the Fund has the right to assert a subrogation lien against such payment, up to the amount paid by the Fund. Very truly yours, John T. Kupchinsky Director, Bureau of Workers Compensation JTK/ck Enclosure