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Pennsylvania Workers Compensation Insurance Bureau

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					                                                                                                                  EMPLOYEE SOCIAL SECURITY NUMBER
    COMMONWEALTH OF PENNSYLVANIA
   DEPARTMENT OF LABOR AND INUSTRY
                                                  PETITION FOR COMMUTATION OF                                      444-22-3333
   BUREAU OF WORKERS’ COMPENSATION            COMPENSATION UNDER THE PENNSYLVANIA
    1171 S. CAMERON STREET, ROOM 103
        HARRISBURG, PA 17104-2501
                                               WORKERS’ COMPENSATION ACT OF 1915                                      DATE OF INJURY
          (TOLL FREE) 800-482-2383                 AS REENACTED AND AMENDED                                               01/24/2001
                                                                                                                    MONTH           DAY                 YEAR
                                                                                                              PA BWC CLAIM NUMBER (IF KNOWN)

                                                                                                                  7654321
  EMPLOYEE                                                                              EMPLOYER
  First Name          Ira                                                               Name        Boscov's Coventry Mall
  Last Name         Sadsack                                                             Address     Coventry Mall
  If Deceased - Dependent, Guardian                                                     Address
  First Name                                                                            City/Town     Pottstown             State      PA      Zip     19465
  Last Name                                                                             County
  Address           51 Gottasue Blvd.                                                   Telephone                                FEIN
  Address                                                                      VS INSURER or THIRD PARTY ADMINISTRATOR (if self insured)
  City/Town        Reading                                                              Name         Allstate Insurance Company
  State      PA                 Zip    19602                                            Address     P.O. Box 61578

  County      Berks                                                                     Address
                                                                                        City/Town   King of Prussia         State   PA         Zip    19406
  Telephone
                                                                                        Telephone 800 551          0271          Bureau Code
                                                                                        County
                                                                                        Claim #                                         FEIN


  Compensation presently payable under: (check one)                         Notice of Compensation Payable                 Award
                                                                            Agreement                                      Supplemental Agreement


TO YOUR HONORABLE JUDGE:
I, Ira M. Sadsack                                                     employee             dependent or guardian               employer

hereby petitions your honorable Judge to commute the sum of $ 2500                                                                                   representing

future installments of compensation payable in the captioned case, as provided under Section 316 of the Pennsylvania

Workers’ Compensation Act, and to order payment of said compensation in one lump sum to                                        Ira M. Sadsack

at its then value discounted at five (5) percent interest for the following reasons:
testing




PLEASE ENTER MY APPEARANCE FOR PETITIONER                                     Name of Petitioner or
                                                                              Claims Representative           Ira M. Sadsack
Attorney Name           Warren H. Prince
PA Attorney ID Number         25623                                           Telephone
Name of Firm        Prince Law Offices, P. C.

Address         646 Lenape Road                                                                                                                         11/05/2002
                                                                                   Signature of Petitioner or Claims Representative                      Date
Address

City      Bechtelsville               State    PA      Zip Code 19505

Telephone      610 845      3803


 NOTICE: Petition should be clearly completed, (preferably typed) and original mailed
 to the Bureau at the address in the upper left corner.                                                                          34 1197-1
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-34 REV 11-97

				
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