This government document is issued by Labor & Industry for use in Pennsylvania
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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-10%2520print.pdf&sa=U&ved=2ahUKEwjhn4ju2-mFAxXk4AIHHf-CC-E4WhAWegQIBxAB&usg=AOvVaw0tMtDv6BkjAWM1Dsw0u4h4