Section 304.2 Application For Religious Exception Of Specified Employes {LIBC-14A}

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION SECTION 304.2 APPLICATION FOR RELIGIOUS002 EXCEPTION OF SPECIFIED EMPLOYEES FROM002 THE PROVISIONS OF THE PENNSYLVANIA002 WORKERS222 COMPENSATION ACT002 1.003 Name of employer FEIN# 2.003 Address3.003 Employer is Sole Proprietor Partnership Corporation 4.003 Total number of employees for whom exception is sought5.003 List the name, address, Social Security Number and date of birth for each employee requesting exceptionunder the Pennsylvania Workers222 Compensation Act. NOTE: For each employee listed, one of the followingmust be submitted with this form: An executed and notarized copy of Form LIBC-14B, Employee222s and attach separate list(s).002 This application must be 002 Employer222s signature 003 Employer222s name (typed/printed) Note: 003 *14A*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com