Benefits were properly suspended after the claimant returned an employment verification form by fax which was signed but not dated.

The claimant filed a claim petition for an injury he sustained while working for the employer. While the claim petition was pending, the employer sent the claimant an “Employee Verification of Employment, Self-Employment or Change in Physical Condition Form” (LIBC-760). The claimant was instructed to sign, date and return the form within 30 days. The form was sent on January 18, 2010, and returned by fax on February 22, 2010. On April 13, 2010, the forms were rejected by the employer since they were not the originals and were not dated. About 30 days thereafter, the claimant returned the form by hand delivery, but the form was still not dated. The claim petition was granted, and the employer then sent the claimant a notification of suspension because he had not properly completed and returned the LIBC-760 to the employer. The claimant then mailed a second LIBC-760 to the employer which was dated, and the employer promptly reinstated benefits. The claimant filed a penalty petition, alleging that the employer violated the Act for suspending benefits and sought a reinstatement of benefits for the period benefits were suspended.

The judge dismissed the claimant’s petitions, concluding that the claimant’s failure to date the form on a line that was located next to the signature line was a fatal omission. The claimant appealed to the Appeal Board, and the Board affirmed the judge’s decision.

On appeal to the Commonwealth Court, the claimant argued that a facsimile transmission of the LIBC-760 form was proper, especially since the fax provides the date. The claimant also argued that his LIBC-760 form was not defective because it was undated because, according to the claimant, the date was established by the fax. The Commonwealth Court agreed that transmission of an LIBC-760 form by facsimile is proper. However, they rejected they claimant’s argument that the form was not defective because the date was contained on the fax. According to the court, there was no way of determining from the fax when the claimant signed the form. This would have an impact on when the employer could send another form to the claimant, which they are entitled to do every six months. The court held that the signature and date are essential to an unsworn statement being given and that the date is necessary to confirm the substance of the statements made in the form as of a date certain.

Case Law Alerts, 2nd Quarter, April 2014