BCPO-2606, PILS Estimate Net Request
BCPO-2606 Rev 06.02.04
BUREAU OF COMMONWEALTH PAYROLL OPERATIONS
DISABILITY PROCESSING SECTION
PAID INJURY LEAVE SUPPLEMENT (PILS)
ESTIMATED NET REQUEST
Please e-mail the PILS Estimated Net Request to the Bureau of Commonwealth Payroll Operations, Disability Processing Section, CO-Disability@state.pa.us. The subject line of the e-mail should be: PILS Form [Personnel Area #,] [Only departments 11, 21, and 26 needs Org #]. Having the required information readily available will expedite the process. You should receive a response in 24 hours or less.
Note that a PILS Estimate is not required
if the employee does not have an available leave balance
To navigate in this form please use the tab key –
if you hit the enter key it will add lines.
|DATE: | |TIME: | | | |
|REQUESTOR NAME: | |REQUESTOR PHONE #: | |
|PerSonnel Area: | |FACILITY: | |
|EMPLOYEE NAME: | |Personnel #: | |
|SS #: | |INJURY DATE: | |BARGAINING UNIT: | |
|IS THIS A RECURRENCE? | |IS THIS A WAGE EMPLOYEE? | |
|DATE OF FIRST ABSENSE FROM WORK (THIS OCCURRENCE): | |
|FOR BUREAU OF COMMONWEALTH PAYROLL OPERATIONS USE ONLY |
| | | | | | | |
|Gross | |Compensation | |Retirement | | |
|Salary | |Payment | |Contribution | | |
| | | |RESPONSE PROVIDED | | |
|PREPARED BY | |DATE | |TIME | | |
|Annual Lv Bal | |Sick Lv Bal | |Personal Lv Bal | | |
ESTIMATED PAID INJURY LEAVE SUPPLEMENT BIWEEKLY NET $
(Amount to be used on the Leave Election Form and the Notice of Injury Leave/Windfall letter.)
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