Notice of Workers' Compensation Denial

Labor & Industry

This government document is issued by Labor & Industry for use in Pennsylvania

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File Details: PDF (218 KB)
Source
https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:1wdjf9sxttm&q=https://www.dli.pa.gov/Businesses/Compensation/WC/claims/wcais/Documents/wcais%2520forms/LIBC-496.pdf&sa=U&ved=2ahUKEwiqv5em2emFAxX0zwIHHTi7CAU4RhAWegQICBAB&usg=AOvVaw2xS-ZDboxYXqT4PubCagjd

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