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Supplemental Information Addendum To Annual Report Of Runoff Group Self-Insurance Fund LIBC-371 - Pennsylvania

Supplemental Information Addendum To Annual Report Of Runoff Group Self-Insurance Fund Form. This is a Pennsylvania form and can be used in Workers Comp .
 Fillable pdf Last Modified 4/2/2014
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DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION SUPPLEMENTAL INFORMATION ADDENDUM TO ANNUAL REPORT OF RUNOFF GROUP SELF-INSURANCE FUND FISCAL AGENT (if different from Fund Administrator) Company name Contact person Address Address FUND ADMINISTRATOR Company name Contact person Address Address City/Town Telephone Email State ZIP City/Town Telephone Email State ZIP APPLICATION CONTACT (if different from Fund Administrator) Company name Contact person Address Address City/Town Telephone Email State ZIP 1. Provide the following information about all companies, except the claims service company, which will be providing services to the Runoff Fund (attach additional sheets if necessary). Company name Services provided 2. Provide the following information about the Board of Trustees (attach additional sheets if necessary). Name of trustee Company Title or position Employer Information Services 717.772.3702 Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447 Hearing Impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991 Email ra-li-bwc-helpline@pa.gov Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-371 REV 09-13 *371* American LegalNet, Inc. www.FormsWorkFlow.com
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