Pennsylvania workers compensation application 2026

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  1. Click ‘Get Form’ to open the Pennsylvania Workers Compensation Premium Credit Application in the editor.
  2. Begin by filling in your Bureau File Number, Name on Insurance Policy, Insurance Company, and Policy Number. Ensure all fields marked with an asterisk (*) are completed as they are mandatory.
  3. Enter the Effective Date of your policy. This is crucial for determining eligibility for premium credits.
  4. For each construction classification, report the total Pennsylvania wages paid this quarter and the total hours worked, including overtime. Use the provided examples as a guide.
  5. If applicable, indicate whether you are engaged in a Long Term Construction Project by checking 'YES' or 'NO'.
  6. Complete the certification section at the bottom of the form by providing your name, title, telephone number, address, and email address. Make sure to sign and date the application.

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