RULES OF THE Pennsylvania Workmen's Compensation Board ISSUED BY THE WORKMEN'S COMPENSATION BUREAU OF THE Department of Labor and Industry Harrisburg, Pennsylvania Effective January 1, 1920. THE WORKMEN'S COMPENSATION BOARD HARRY A. MACKEY, Chairman PAUL W. HOUCK BENJAMIN 3. JARRETT CLIFFORD B. CONNELLEY, Ex-Offlcio LEE SOLOMON, Secretary. HARRISBURG, PENNA. : J. L. L. KUHN, PRINTER TO THE COMMONWEALTH 1919 RULES OF THE Pennsylvania Workmen's Compensation Board ISSUED BY THE WORKMEN'S COMPENSATION BUREAU OF THE Department of Labor and Industry Harrisburg, Pennsylvania Effective January 1, 1920. THE WORKMEN'S COMPENSATION BOARD HARRY A. MACKEY, Chairman PAUL W. HOUCK BENJAMIN J. JARRETT CLIFFORD B. CONNELLY, Ex-Officio LEE SOLOMON, Secretary. HARRISBURG, PENNA. : J. L. L. KUHN, PRINTER TO THE COMMONWEALTH 1919 nW r 5^T <2) INDEX. AGREEMENTS : Page. To be executed by dependents in case of deatb , 8 Supplemental, 8 For compensation must be executed when disability continues for more than ten days 7 For death, . .- 8 For disability , 7 How and when it should be drawn , 7 By minors , 9 To be drawn substantially in accordance with the forms of the Board, 11 AMENDMENT : Disposition of, by the Board , 12 To pleadings , 12 Of the record substituting the State Fund for the employer, 13 APPEALS : Bond to be filed under certain circumstances, 18 By either party from the action of the Referee on a petition, when as- signed to him , 17 From Referee must set out error complained of, 17 How to be heard , 17 Statements to be contained in the said appeal, 17 When to act as supersedeas, 18 When to be heard by the Board 18 BOARD : May hear petitions for review s termination or modification, or refer the same to a Referee, 16 BRIEFS : When to be filed , 18 CLAIM PETITION : Claim petition to be returned to claimant when necessary information is lacking 12 COMMUTATION : Petitions for, 16 COMPENSATION : How the day of its first payment is determined, 7 COSTS : Bill of costs to filed with the Secretary, 15 Exceptions %o bill of cost may be filed within three (3) days, 15 Of first petition to be paid before second is heard, 15 Reasons for disposition of the same under certain circumstances to be set out by Refen>e , , 15 To be taxed by Referee or Board 15 (3) DEATH : Page. Agreements for, 8 Proof of 8 DISABILITY : Time for computing when the same becomes compensable, 7 DISTRICTS : Boundaries and designation of 21 EXCEPTIONS : To the testimony to be noted by the Referee, 14 FORMS : List of, 18-19-20 HEARINGS : By the Referee , 14 Shall be open to the public, 14 INVESTIGATION : By referee or Inspector, 13 Power of the Referee to make, 14 ISSUE: Of fact raised by petition for amendment and answer to be heard by the Board or a Referee designated by the Board 12 MEDICAL AND HOSPITAL SERVICES: To be recovered by claim petition filed by the employe, if compensation agreement fails to provide for same, 7 NOTICES : To be sent to counsel, insurance carrier, or other representatives of the party in interest , 14 OATHS : To be administered by Referee and clerks without charge, 12 PETITIONS : For commutation, contents of, method of hearing, 16 For commutation may be referred to Referee for hearing, 16 For determination of compensation due under agreed facts, forms to be used and statements to be therein contained, 16 For review, termination or modification of agreement or award, 16 Method for disposing of same, 16 PLEADINGS : Amendment of, 12 PHYSICIAN : How appointed 13 PRACTICE : By a Referee when petitions have been referred to him , 17 Referee shall proceed with hearing on failure of. either party to appeal when proof is presented that notice of the same had been served, .. 15 Where no answer is filed to petition , 17 • 5 i PROCEDURE : Page. Before Referee , 13 Rules of, 11-12 When either party fails to appear at hearing, 14 REFEREE : Assistance to be given by to unrepresented parties, 14 Duties of, 13 Duties of, upon notice of appeal, 18 Location of, and district assignments, 21 HE-ASSIGNMENT : Of petition for convenience, 13 RECEIPTS : Final, when employe refuses to sign, 8 When they must be filed with the Bureau, 7 No receipts for compensation should be approved unless agreement has been previously filed and approved, 7 RE-MARRIAGE : Of a widow 9 Where widow refuses to execute supplemental agreement, 9 Supplemental agreement providing for changed liability, 9 RULES : For ascertaining wages, 10 Of procedure , 11-12 STATE WORKMEN'S INSURANCE FUND : To be notified when it is the insurer, 13 SUPERSEDEAS : Filing of petition to terminate or modify to act as 17 SUPPLEMENTAL AGREEMENTS : Effect of, 8 In relation to 8-i) Practice when employe refuses to sign, 8 When employer refuses to execute, 8 TESTIMONY : To be taken stenographically, 14 WAGES : Rules for ascertaining, 10 WITNESSES : To receive fair and courteous treatment 14 6 All persons having occasion to use any of the forms may obtain copies of the same by applying to the Workmen's Compensation Bu- reau, Department of Labor and Industry, Harrisburg. January 1, 1920. RULES AND INSTRUCTIONS FOR THE EXECUTION OF COM- PENSATION AGREEMENTS. 1. Agreements for Disability. No agreement is necessary unless the disability resulting from the accidents lasts more than ten days. If the employer has failed to provide the surgical, medical and hospital services required by the Act the employe may file a claim petition for such expenses. In computing the time when the disability becomes compensable, the day upon which the accident happens is to be considered one of the ten days. Thus, if an accident occurs at any hour on January 1, the right to compensation begins on January 11. Compensation agreements, as provided by the Act, must be executed (substantially as provided in Form W 14) whenever the disability continues for more than ten days. No receipt for compensation from an employe will be approved as a discharge of the liability created by Article III, unless an agreement for compensation has been mailed or delivered to the Board and approved by it. Receipts for compen- sation payments must be filed with the Bureau at least quarterly in all cases where disability continues for a period of more than three months. A final receipt with suffice in cases in which disability is less than three months' duration. When the accident has caused the loss of a hand, foot, arm, leg or eye or the use thereof, an agreement should be made, immediately after the expiration of the first ten days, for the payment of com- pensation for the number of weeks appropriate to the particular dis- memberment. When the disability is one of uncertain duration, an agreement should be made not more than three weeks after the disability begins. This agreement should provide that compensation be paid during the full "500 weeks," when the disability is total, or "300 weeks," when it is partial "or until this agreement has been terminated by supplemental agreement or final receipts approved by the Workmen's Compensation Board or by the order of the Board." The agreement must state the amount of compensation payable weekly and the total amount payable under it, which is the weekly compensation multi- plied by the number of weeks (500 or 300) during which compen- sation is payable. A supplemental agreement (substantially as provided in Form No. 14a) modifying the agreement or award, should be executed, if the employe's {Usability changes from total to partial, by his regaining his ability to work, though at a reduced earning power, or from partial to total, where an injury, which had originally reduced his earning power, increases so as to completely destroy it. If the em- ploye recovers from his injury so as to regain his full earning power, which is generally known by his return to work at his original wages, a supplemental agreement (substantially as provided in Form W 14a) may be executed or final receipts (substantially as provided in Form W 51b), setting forth the manner in which and the date on which the employe's disability terminated and signed by him in the presence of an .attesting witness, may be filed with the Workmen's Compensation Bureau at Harrisburg. If the employe refuses to execute such a supplemental agreement or sign such final receipts, when his disability has diminished or ceased, or if the employer should refuse to execute such an agreement when the employe's disability has increased, a petition can be pre- sented to the Board (substantially as provided in Form W35), praying it to order the agreement or award modified or terminated. The filing of such a petition will suspend, until the petition be granted or refused, the payment of compensation to such an extent as the facts alleged therein would, if proved, require. If any employe, entitled to compensation for disability, under an agreement or award, dies as a result of his injury, leaving dependent or dependents, an agreement (substantially as provided in Form W- 15) should be made with the dependent or dependents of the employe. Such an agreement stating, as it must, the date of the employe's death, will of its own force and without any further agreement, termi- nate the disability agreement as of the date of such death. Should there be no dependents of such an employe the Board will accept as prima facie proof of the termination of liability under an agreement or award a certified copy of the death certificate of such employe together with the last receipt signed by him. II. AGREEMENTS FOR DEATH COMPENSATION. When the accident causes death, an agreement (substantially as provided in Form W 15) should be executed between the employer and the dependent, dependents or personal representative. Wherever the liability of an employer for death compensation under an agreement or award has been terminated by the marriage of a w idow, there being no child entitled to compensation, or by the death of all the dependents, a supplemental agreement (substantially as provided in Form W 15) terminating the compensation agreement or 9 the award may be executed or receipts (substantially as provided in Form W 15c) setting forth the manner in which and the date on which the dependency of the person or persons entitled ceased and signed by the widow, guardian of the dependent child or children, or brother or sister or by the personal representative of the father or mother, in the presence of an attesting witness, shall be filed with the Work- men's Compensation Bureau at Harrisburg. Where the marriage of a widow or the death of a dependent changes the amount of compensation of the person or persons to whom it is payable, but does not entirely extinguish the employer's liability under an award or agreement, a supplemental agreement (substan- tially as in Form W 15a) should be executed. If the widow upon marriage, or the remaining dependents, where there were several dependents and one dies, shall refuse to execute such a supplemental agreement or sign such a receipt as the facts require, a petition may be presented to the Board praying it to modify or terminate the compensation agreement or award, and the filing of such a petition will, until the petition be granted or re- fused, suspend the payment of compensation to such an extent as the facts alleged therein would, if proved, require. Where an agreement or award is made in favor of a single depend- ent and such dependent dies, the Board will accept as prima facie proof of the termination of the liability under such agreement or award a certified copy of the death certificate of such dependent together with the last receipts signed by him or her. AGREEMENTS BY EMPLOYES AND DEPENDENTS UNDER THE AGE OF TWENTY-ONE. All agreements, supplemental agreements and receipts executed by an employe of whatever age or by a dependent over the age of sixteen shall be as valid and binding as though such employe or dependent were over the usual legal age of twenty-one. The signature of the guardian is therefore only necessary where the sole dependents are children below the age of sixteen years. 10 EULES FOE ASCEETAINING WAGES. The compensation under Sections 306 and 307 (as amended) is a slated percentage of the employe's weekly wages. It is therefore necessary in every case to ascertain the weekly wages of the employe. Section 309 (as amended) defines wages as "the money rate at which the service is recompensed under the contract for hiring in force at the time of the accident." To ascertain the wages, add to the sum agreed to be paid the value of any board and lodging supplied by the employer. (a) If the value of the board and lodging is fixed by the contract of hiring, add the value so fixed. (b)l If no value is put upon the board and lodging by the contract of hiring, add 50 cents per day for board and 50 cents per day for lodging. But do not add any gratuities given the employe by the employer or other, such as tips or presents. Deduct from the sum agreed to be paid for the employe's services, any amounts, deducted by the employer for labor furnished or paid for by the employer and necessary for the performance of the em- ploye's contract of employment. But do not deduct: 1. Amounts earned as over-time. 2. The value of materials, supplies, tools and other things neces- sary for the performance of the employe's contract of employment, through furnished by the employer and charged against the employe's earnings. 3. Any sums due the employer for rent or supplies other than those necessary for the employe's use in the performance of his labor, even though supplied by the employer under a contract which gives him the right io deduct such sums, from the wages from time to time due the employe. When the wages at the time of the accident are fixed by the week, the weekly wage so fixed shall be the basis for computing compensa- tion. When the wages are fixed on a monthly basis, ascertain the weekly wages by multiplying the monthly salary or wages by 12 and dividing by 52. When the wages are fixed by the year, divide the yearly wage by 52. 11 Where in a continuous employment the rate of wages is fixed 'by the day, hour or by the output of the employe, multiply by five and one-half, the employe's average earnings, at such rate for a working day, unless the employe customarily worked more than 5£ days a week in which case multiply by the number of days customarily worked per week. To find "average earnings for a working day" — take total earnings for six months preceding the accident, or so much thereof as employe has worked for the same employer and divide such total earnings by the number of 'working days' in such period. "Working Days" shall be construed to mean total number of days in the period of employment covered, according to the calendar, less: (a) Sundays f unless the employe (b) Legal Holidays (c) Half holiday for each week (d) Days employe was prevented from working through no fault of his own. actually worked on L such days. Section 309 (as amended) makes very clear and definite provisions for the exceptional cases where the employment is seasonal or where by reason of the short time which elapses between the hiring and the accident, the earnings of the employe to not furnish a satisfactory basis for computing his wages or where an employe prior to the accident has been working for two or more employers under con- current contracts of employment. RULES OF PROCEDURE. 1. All agreements, petitions and answers must be substantially in accordance with the forms prepared by the Board. 2. If the facts agreed upon in a compensation agreement differ materially from the facts stated in the report of the accident and reports supplemental thereto made to the Department of Labor and Industry, the agreement will not be approved until the discrepancy is explained to the satisfaction of the Board. 12 3. Any petition which does not contain the information required by Forms W L8 and W 1!>, will not be assigned to a Referee for hear- ing, but will be returned to the claimant inorder that he may supply the information not given. 4. Compensation Referees and their clerks shall administer oaths free of charge and shall, when requested to do so, assist any party in drawing a claim petition, answer or any other paper necessary for the administration of the Workmen's Compensation Act. AMENDMENT OF PLEADINGS. 1. Any petition, answer, appeal or other pleading in any matter pending before the Board may be amended before final action by the Board by a written agreement or by a petition filed with the Secre- tary of the Board at the principal office at Harrisburg. 2. Any petition which has been assigned by the Board to a Re- feree, any answer thereto, or other pleading therein may be amended prior to an award or disallowance by the Referee by written agree- ment or by petition filed with the Referee at his office. 3. A copy of such petition to the Board or Referee must be served by registered mail upon each adverse party or his counsel. The petition must set forth under affidavit the original pleading, the amended pleading desired, the reasons why the amendment is desired and such facts as are alleged as grounds for amendment and the date of mailing the copy of the petition to each adverse party. 4. Any adverse party may, within six days after the copy of the petition is mailed to him, file an answer under affidavit denying any fact alleged in the petition and giving any other reason w T hy the amendment prayed therein should not be granted. 5. The petition will be disposed of by the Board or Referee with- out argument. 6. Any issue of fact raised by a petition for amendment and answer thereto, filed with the Secretary of the Board, may be heard by the Board or referred to any Referee, whose finding therein shall be final. 13 PROCEDURE BEFORE REFEREES. DUTIES OF A REFEREE BEFORE A HEARING. 1. When a claim petition is assigned to a Referee, he should en- deavor to bring the parties to an understanding and to induce them to settle the claim, without further litigation, by an appropriate compensation agreement. 2. The Referee may continue the hearing and make an investiga- tion either in person or through an inspector of the Department of Labor and Industry, when in his judgment such an investigation is necessary to determine any question of fact raised by the pleadings or testimony or when there is a discrepancy between the facts set forth in the claim petition and those stated in the reports of the accident made to the Department of Labor and Industry. 3. Where any medical fact is put in issue by a petition and answer the Referee may with the consent of the Board appoint an impartial physician or physicians to examine the physical condition of the peti- tioner or defendant to the petition and report thereon. 4. When a claim petition has been assigned to a Referee and the only fact denied in the answer is one which can be more conveniently investigated in another compensation district, the petition may be assigned to the Referee of such other district. 5. W T hen one of the allegations denied in an answer to a claim petition is the disability of an employe or the status of a dependent, this question may be referred through the Bureau by the Referee to whom the petition is assigned, to the Referee of any district in which the question can be more conveniently investigated, whose finding thereon when made to the original Referee shall be of the same effect as a finding of the original Referee. 6. When it comes to the notice of any Referee to whom a claim petition has been assigned whether before, at or after hearing held thereon that the State Workmen's Insurance Fund is the insurance carrier of the employer defendant, the Referee shall stay all pro- ceedings and continue any hearing set or held and shall immediately notify the State Workmen's Insurance Fund at its principal office at Harrisburg. Upon receipt of a notification from the State Fund that the em- ployer against whom the petition has been filed has notified the fund of the accident, as required by Section 20 of the Act creating the State Fund, the Referee shall amend the record in the case so as to make the State Fund the defendant instead of the employer. 14 When the Referee files his award or disallowance with the Bureau, he shall notify the Bureau that he has amended the record as afore- said, so as to enable the Bureau to amend its record accordingly. 7. When any counsel, insurance carrier or representative of any party in interest shall have filed his appearance in writing the Re- feree shall sorve all notices and other papers upon him and not upon the party whom he represents, and shall return the appearance as part of the record to the Bureau with his award or disallowance of compensation. HEARINGS. 1. The Referee shall hold a hearing at the place, within his dis- trict, most convenient to all parties concerned. 2. All hearings before the Board or a Referee shall be open to the public. 3. The Referee shall cause the testimony produced at the hearing to be taken stenographically. Whenever the question of admissibility of testimony is presented for the consideration of the Referee he shall promptly rule upon the same and note an exception to either party tequesting it. 4. The Referee shall require that both parties and counsel shall treat all witnesses fairly and courteously. 5. W T hen either a claimant or defendant is not represented by counsel, the Refciee shall advise him as to his rights, aid him in ex- amining witnesses and give him all assistance which is compatible with the judicial position of the Referee. In all cases when the defendant shall fail to file an answer the Referee shall have the same power to make an investigation in person or by physicians or experts as through an answer has been filed. PROCEDURE, WHEN EITHER PARTY FAILS TO APPEAR AT HEARING. Where a claimant fails to appear at a hearing set by a Referee of which he or his counsel of record has received timely notice and does not file with the Referee before or at the hearing a legal excuse for 15 his non-appearence, the Referee shall dismiss the petition without prejudice to the right of the claimant to file a second petition at any time within the period of limitation. If a second petition is filed, it will not be assigned to any Referee until the claimant has satisfied the Board that he has paid the costs incurred in the first proceedings as taxed by the Board. If a defendant shall fail to appear at a hearing set by the Referee, of which such defendant or his insurance carrier or counsel of record has had timely notice, the Referee shall proceed with the hearing. COSTS. Costs incurred by a party will not be included in an award unless the part shall, within three days after final hearing, file with the Ref- eree or with the Secretary of the Workmen's Compensation Board, if the case is heard by the Board, an itemized statement of the costs, giving the names of witnesses, days of actual attendance, mileage, ser- vice of subpenas, and shall verify the same by affidavit that the wit- nesses named were material and in actual attendance at the time specified and shall serve a copy thereof by mail upon the adverse party or his council or insurance carrier. The adverse party may within three days after such copy has been served upon him file exceptions thereto with the Referee or with the Secretary of the Board, as the case may be, and the Referee or Board shall fix a time and place for hearing the same. The Referee or Board, as the case may be, shall tax the costs in- curred by the parties as shown by the itemized statement filed by them and shall place such costs as are allowed by him together with those incurred by the Referee, upon the unsuccessful party, unless the special circumstances of the case make it proper to otherwise dispose of them. In such case he may put upon each party the costs incur- red by him or he may divide the costs in such proportion as he shall deem proper. If the Referee shall dispose of the costs otherwise than by imposing them upon the unsuccessful party, he shall set forth fully in his award his reasons for so doing. The costs of the hearing shall be paid to the Referee or Secretary and shall be paid over by him to the parties entitled thereto, unless the party on whose behalf the costs have been incurred shall present receipts from the parties entitled thereto, in which case the costs so paid by the party shall be paid to him. 10 PETITIONS TO THE BOARD. PETITION FOR DETERMINATION OF COMPENSATION DUE UNDER AGREED FACTS. Petitions to the Board praying for the determination of compensa- tion due under facts agreed upon by the parties shall state whether the parties desire the case to be determined : i a ) Without argument. (b) On briefs submitted or, (c) On oral or written argument in person or by counsel. PETITIONS FOR COMMUTATION. Compensation can only be commuted by an order of the Board and all petitions for commutation must be therefore determined by the Board. Every petition for commutation must contain a full detailed state- ment of the circumstances which are alleged to require the commuta- tion and must be sworn to by the petitioner and filed with the Secre- tary of the Board. The Board may either itself investigate the facts or may refer the petition to a Referee to hear the facts and reports his findings there- on to the Board. The petitioner must appear in person' unless his need is urgent or illness or other 'sufficient cause prevent his appear- ance before the Board or Referee, at the hearing held to ascertain the facts. PETITIONS FOR REVIEW OF AGREEMENT OR THE TERMI- NATION OR MODIFICATION OF AGREEMENT OR AWARDS. All petitions for the review of an agreement, or for the termination or modification of an agreement or award will be disposed of as fol- lows: 17 1. The Board may, (a) Order the case heard by the Board itself on evidence to be taken before it. (b) It may order the petition to be heard and determined by the Board itself but may refer the petition to a referee to take testimony and report to the Board his findings of fact thereon. (c) The Board may assign the case to a referee to be heard and determined by him. 2. If no answer is filed within ten days after the notice of the pe- tition has been served on all adverse parties, the Board or the Referee, if the petition has been assigned to a Referee for determination, will dispose of the matter upon the facts alleged in the petition. 3. The Referee shall fix a time and place for the hearing and shall notify all parties thereof and shall hear and determine the matter, and return his findings to the Bureau in the same manner as in the case of a claim petition. 4. A party against whom the Referee has made a finding may ap- peal to the Board on the same grounds and in the same manner as in 1he case of an appeal from a Referee's award or disallowance of com- pensation. 5. The filing of a petition to terminate or modify a compensation agreement or award, will operate as a supersedeas and will suspend the payment of compensation fixed in the agreement or by the award, in whole of in such parties as the facts alleged in the petition, would if proved, require. APPEALS FROM REFEREES. 1. When the appeal is taken from the decision of a Referee on questions of fact or law, the appellant must set forth specifically on and fully the errors of which he complains, and shall specify whether he desires the case to be heard: (a) Without argument. (b) On briefs submitted, or (c) On oral argument in person or by counsel. 2. Appeals must be filed in duplicate. :j. Appeals sluill Ite heard without the parties appearing in person or by counsel unless the appellant shall at the time of filing his appeal notify the Board thai he desires to appear in person or by counsel, IS or the apellee shall within five days after notice of the appeal has been served upon him notify the Board that he desires to appear in person or by counsel. 4. If neither party has notified the Board of his desire to appear ii. person or by counsel, the Board will consider the appeal at the next meeting or sitting held by it after the expiration of ten days from the date of service of notice or appeal upon the appellee. 5. The appellant or appellee may file a written brief at or prior to the time his appeal is heard. All briefs shall be filed in triplicate. 6. An appeal taken by the State Workmen's Insurance Fund or by an employer, who has complied with Section 305, will operate as a supersedeas and will suspend the payments ordered by the award appealed from, in whole or in such part as the appeal, if sustained, would require. An appeal by an employer who has not complied with Section 305, will not operate as a supersedeas, unless such em- ployer shall file a satisfactory bond in an amount sufficient to secure the payment of the compensation, due under the award at the date ot the appeal and the compensation which may accrue during the pendency of the appeal. 7. Whenever the Referee shall receive notice from the Bureau that an appeal has been filed with the Board from his decision in any case, he shall immediately cause the notes of testimony taken iii that case to be typewritten and forward to the Board a copy with the certificate of the official stenographer that they are full and cor- rect. LIST OF FORMS FOR PUBLIC USE. Form W 1 —Employer's Notice to his Employe of his Rejection of Article III of the Workmen's Compensation Act of 1915. Form W 2 — Notice to Laborers and Assistants not directly em- ployed by the Principal Employer of his Rejection of Article III of the Workmen's Compensation Act of 1915. Form W 3 — Notice to Employer or Employe of Laborer's Re- jection of Article III of the Workmen's Compensation Act of 1915. Form W 4 — Employer's Notice of Termination of Rejection or Ac- ceptance of Article III of the Workmen's Compensation Act of 1915. 19 Form W 5 — Employer's Notice to Laborers and Assistants of Termination of Kejection or Acceptance of Article III of the Workmen's Compensation Act of 1915. Form W 6 — Employe's Notice of Termination of Rejection or Ac- ceptance of Article III of the Workmen's Compensation Act of 1915. Form W 7 — Proof of Service of Employer's Notice of his Rejec- tion or Termination of his Rejection or Acceptance of Article III of the Workmen's Compensation Act of 1915. Form W 7 a — Proof of service of Employer's Notice to his Employes in Manner Permitted by Special Order of the Board. Form W 8 — Proof of Posting Notice to Laborers and Assistants hired by an Employe or Contractor of the Principal Em- ployer's Rejection or Termination of his Rejection of Acceptance of Article III of the Workmen's Compen- sation Act of 1915. Form W 9 — Notice of Proof of Service of Employe's Rejection or Termination of his Rejection or Acceptance of Article III of the Workmen's Compensation Act of 1915. Form W 10 — Employer's Application for the Privilege of Paying Compensation Provided iu Article III of the Workmen's Compensation Act of 1915, without Insurance. Form W 14 — Agreement for Compensation for Disability. Form W 14 a — Supplemental Agreement for Termination or Modifi- cation of a Compensation Agreement or Award for Dis- ability. Form W 15 — Agreement for Compensation for Death. Form W 15 a — Supplemental Agreement Terminating or Modifying an Agreement as to or an Award of Compensation for Death. Form W 18 — Employe's Claim Petition for Compensation for Disa- bility. Form W 19 — Claim Petition for Compensation by Dependents of Deceased Employe. Form W 25 — Appeal from Referee Alleging Error of Law. Form W 26 — Appeal from Referee's Findings of Fact. 20 Form W 27 — Appeal from Keferee on the Ground of Fraud, Coer- cion, or other Improper Conduct of a Party in Interest. Form W 30 — Petition to the Board for the Determination of Com- pensation for Disability under Facts agreed upon by the Parties. Forin W 31 — Petition to the Workmen's Compensation Board to Determine the Compensation Payable under Agreed Facts to the Dependents of Deceased Employe. Form W 32 — Petition for Keview of Compensation Agreement. Form W 33 — Petition by Employer for Commutation of Compen- sation. Form W 34 —Petition by Employe or Dependents for Commutation of Compensation. Foim W 35 — Petition for Termination or Modification of Agree- ment or Award on Ground of Changed Disability. Form TV 36 — Petition by Employer for Modification or Termination of a Compensation Agreement or Award on the Ground of change in the Status of the Dependent or Dependents of a Deceased Employe. I'orm TV 38 — Answer to Petition for the Review of a Compensation Agreement. Form TV 39 — Answer to Petition for the Commutation of Compen- sation Payable under an Agreement or Award. Form TV 40 — Answer to Petition for the Modification or Termina- tion of a Compensation Agreement or Award. Form TV 47 — Petition of Employer for Physical Examination of Employe. Form TV 49 — Petition of Employer for Further Physical Examina- tion of Employe. Form W51 — Receipt of Compensation Paid under a Compensation Agreement or Claim Petition. I'orm TV 51 b— Final Receipt for Disability Paid under -a Compen sation Agreement or Claim Petition. Foim TV 51 c— Final Receipt for Death Paid under a Compensation Agreement or Claim Petition. 21 WORKMEN'S COMPENSATION DISTRICTS. District No. 1 — Bucks, Chester, Delaware, Montgomery and Phila- delphia Counties. Referees: Warren C. Graham. Charles W. Rosier, North American Ruilding, Broad and Sansom Sts., Philadelphia. — Berks, Carbon, Lehigh, Northampton and Schuyl- kill Counties. Referee: Thomas C. Seidel, Uliner Building, 207 N. Center St., Pottsville. District No. 2 District No. 3 District No. 4 District No. 5 — Lackawanna, Luzerne, Monroe, Pike, Susquehanna, Wayne and Wyoming Counties. Referee: George W. Beemer, Union National Bank Building, Lackawan- na and Washington Avenues, Scranton. — Adams, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lancaster, Lebanon, Perry and York Coun- ties. Referee: Chester W. Cummings, Woolworth Building, Grant and Queen Sts., Lancaster. — Bradford, Cameron, Centre, Clinton, Columbia, Lycoming, Mifflin, Montour, Northumberland, Pot- ter, Snyder, Sullivan. Tioga and Union Counties. Referee: W. W. Champion, First National Bank Building, 21 W. 3rd St., Williamsport. — Bedford, Blair, Cambria, Clearfield, Huntingdon, Indiana, Jefferson and Somerset Counties. Referee: Jacob Snyder, Commerce Building, 1434-36 Eleventh Ave., Altoona. District No. 7. —Armstrong, Clarion, Crawford, Elk. Erie, Forest. McKean, Mercer, Venango and Warren Counties. Referee: G. Scott Smith, 216-20 Second St.. Warren. District No. 8 —Allegheny, Beaver, Butler, Fayette, Greene, Law- rence, Washington and Westmoreland Counties. Ref- erees: L. E. Christley, Harry B. Henderson, Hartje . Building. Wood St. and First Ave., Pittsburgh. District No. 6 (22)