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Annual Report Of Accident And Illness Prevention Program Status LIBC-230G - Pennsylvania

Annual Report Of Accident And Illness Prevention Program Status Form. This is a Pennsylvania form and can be used in Workers Comp .
 Fillable pdf Last Modified 1/13/2014
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DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION ANNUAL REPORT OF ACCIDENT & ILLNESS PREVENTION PROGRAM STATUS BY GROUP SELF-INSURANCE FUNDS DD YYYY For fund year MM To MM DD YYYY Insurer code Form must be completed in its entirety! Please make necessary corrections to Item #1a in Item 1b 1a. Fund name and address Fund name Address (line 1) Address (line 2) City State ZIP - 1b. Corrected Name and Mailing Address (if necessary): Fund name Address (line 1) Address (line 2) City State ZIP - 2a. Total Number of Members $I¿OLDWHG ZLWK WKH *URXS 6HOI,QVXUDQFH )XQG 2b. Total Number of Members 5HFHLYLQJ $FFLGHQW ,OOQHVV 3UHYHQWLRQ 6HUYLFHV 2c. Total Amount Spent on $FFLGHQW ,OOQHVV 3URJUDP 6HUYLFHV $ D 7RWDO 1XPEHU RI 5HTXHVWV IRU 3URJUDP 6HUYLFHV 5HFHLYHG E 7RWDO 1XPEHU RI 5HTXHVWV IRU 6HUYLFHV WKDW ZHUH )XO¿OOHG F 1XPEHU RI 0HPEHU 6HUYLFH 5HTXHVWV )XO¿OOHG 9LD 6HUYLFH 9LVLWV If 3a is less than 3b, please attach an explanation labeled item 3. LIBC-230G REV 09-13 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com 0HWKRGV 8WLOL]HG IRU 'HWHUPLQLQJ 3URJUDP 6HUYLFHV &RPPLWPHQWV >0DUN ZLWK DQ [ DOO WKDW DSSO\@ a. Member Contribution (%) f. Incurred Losses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uggestion and Communications Program 0HWKRGV IRU $FFLGHQW ,QYHVWLJDWLRQ DQG 5HSRUWLQJ DQG 5HFRUGNHHSLQJ 2QVLWH 6XUYH\V WR LGHQWLI\ H[LVWLQJ RU SRWHQWLDO DFFLGHQW DQG LOOQHVV KD]DUGV RU VDIHW\ SURJUDP GH¿FLHQFLHV $QDO\VHV RI WKH FDXVHV RI DFFLGHQWV DQG LOOQHVVHV DW WKH PHPEHUV¶ ZRUNVLWH ,OOQHVV 3UHYHQWLRQ 3URJUDP 3URWRFRO RU 6WDQGDUG 2SHUDWLQJ 3URFHGXUHV ZKHQ DSSOLFDEOH WR WKH :RUNSODFH DQG :RUNSODFH (QYLURQPHQWV IRU L LL LLL LY Y YL (OHFWULFDO DQG 0DFKLQH 6DIHJXDUGLQJ 3HUVRQDO 3URWHFWLYH (TXLSPHQW +HDULQJ DQG 6LJKW &RQVHUYDWLRQ /RFNRXW7DJRXW 3URFHGXUH +D]DUGRXV 0DWHULDO +DQGOLQJ Storage and Disposal Procedures &RQ¿QHG 6SDFH (QWU\ 3URFHGXUHV YLL )LUH 3UHYHQWLRQ DQG &RQWURO YLLL 6XEVWDQFH $EXVH $ZDUHQHVV DQG 3UHYHQWLRQ 3ROLFLHV DQG 3URJUDPV L[ [ [L 3URYLGLQJ RU SURSRVLQJ FRUUHFWLYH DFWLRQV LQ WKH DUHD RI LQGXVWULDO KHDOWK VHUYLFHV $FFLGHQW DQG LOOQHVV SUHYHQWLRQWUDLQLQJ SURJUDPV &RQVXOWDWLRQV UHJDUGLQJ VSHFL¿F VDIHW\ DQG KHDOWK SUREOHPV DQG KD]DUG DEDWHPHQW SURJUDPV DQG WHFKQLTXHV 6WDWH WKH 7\SHV RI $FFLGHQW ,OOQHVV 3UHYHQWLRQ 0DWHULDOV 3URYLGHG WR 0HPEHUV >0DUN ZLWK DQ [ WKH W\SHV RI 0DWHULDOV SURYLGHG@ D $XGLRYLVXDO PDWHULDO E 3RVWHUV3D\UROO VWXIIHUV F %RRNOHWV %URFKXUHV 3DPSKOHWV G 5HJXODWLRQV6WDQGDUGV e. Sample Forms LIBC-230G REV 09-13 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com &RQWURO RI ([SRVXUH WR %ORRGERUQH 3DWKRJHQV 3UHRSHUDWLRQDO 3URFHVV 5HYLHZ 2WKHU 3URWRFROV DV PD\ EH $SSURSULDWH IRU WKH *URXS 6HOI,QVXUDQFH )XQG¶V 2SHUDWLRQV >([SODLQ ± ,GHQWLI\ DV ,WHP DGGLWLRQDO VKHHW@ [L RQ 3URYLGLQJ RU SURSRVLQJ FRUUHFWLYH DFWLRQV LQ WKH DUHD RI LQGXVWULDO K\JLHQH VHUYLFHV I 6DPSOH SURJUDPV J $ZDUGV K 2WKHU >([SODLQ ± LGHQWLI\ DV LWHP K RQ DGGLWLRQDO VKHHWV@ L 2SWLRQDO :KDW LV WKH FRVW RI WKHVH Materials $ &KHFN WKH ER[HV RI WKH PHWKRGV XVHG WR GHWHUPLQH WKH HIIHFWLYHQHVV RI WKH $FFLGHQW 3UHYHQWLRQ 3URJUDP , ,OOQHVV 26+$%/6 LQFLGHQFH UDWH FRPSDULVRQ UHODWHG WR \RXU 1RUWK $PHULFDQ &ODVVL¿FDWLRQ 6\VWHP 1$,&6 &RGH
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