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Pennsylvania LIBC-134: Dismemberment Chart (Hand)

Pennsylvania's Bureau of Workers' Compensation uses this two-page chart when a work injury results in loss of fingers or part of the hand, which can qualify for specific-loss benefits under Section 306(c) of the Workers' Compensation Act. A physician marks the level of amputation on a labeled diagram of the hand bones. Page one ties the chart to the claim in WCAIS with employee, employer, insurer and injury details.

Who completes it

A physician marks the hand diagram and is identified in the 'Marked by M.D.' block. The form does not say who fills the identification fields on page one, which cover the employee, employer, insurer or third-party administrator, and injury details.

Submitting and payment

How to submit it
The chart goes back to the employer or insurer with the claim documents; the Bureau lists it as submitted online or by mail, with a copy to the claimant if the form is used.
Who pays
The chart sets no fee and has no billing section.

Good to know

  • The diagram labels the distal, middle and proximal phalanges, the metacarpals and the carpal bones, so the marking can show exactly where the loss begins.
  • Page one records the WCAIS claim number, the part of body injured, the nature of injury, an accident narrative, and a box for occupational disease.
  • The foot version is LIBC-134F; both charts carry the REV 09-22 date and the same Section 306(c) heading.
  • The form warns that knowingly filing misleading or incomplete information violates Section 1102 of the Act and can bring insurance fraud penalties under 18 Pa.C.S. 4117.

Get the official form

Download the current version from the source each time; forms change without notice.

Dismemberment Chart (Hand)

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What is the LIBC-134 used for?

It documents a hand or finger amputation for specific-loss benefits under Section 306(c) of the Pennsylvania Workers' Compensation Act. The physician marks the diagram to show the level of the loss, and the chart travels with the claim documents in WCAIS so the specific loss can be identified.

Is there a Pennsylvania dismemberment chart for the foot?

Yes. LIBC-134F is the companion chart for foot and toe losses and shows the dorsal surface of the left foot with labeled tarsal bones, metatarsals and phalanges. LIBC-134 covers the hand. Both use the same first page of claim and injury information.