Pennsylvania > Workers Comp

Supplemental Information Addendum To Application As A Group Workers Compensation Fund LIBC-369 - Pennsylvania

Supplemental Information Addendum To Application As A Group Workers Compensation Fund Form. This is a Pennsylvania form and can be used in Workers Comp .
 Fillable pdf Last Modified 4/2/2014
Get this form for FREE as a print-only pdf

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION SUPPLEMENTAL INFORMATION ADDENDUM TO APPLICATION AS A GROUP WORKERS' COMPENSATION FUND Name of fund applicant Describe briefly the general operating characteristics of the prospective fund members. FUND ADMINISTRATOR Company name Contact person Address Address City/Town Telephone Email State ZIP FISCAL AGENT Company name Contact person Address Address City/Town Telephone Email (if different from Fund Administrator) (if different from Fund Administrator) State ZIP APPLICATION CONTACT 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 applicant (attach additional sheets if necessary). Company name Services provided LIBC-369 REV 09-13 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com 2. Excess Insurance If the applicant intends to obtain excess insurance coverage, provide the following information: Specific Proposed retention amount: $ Proposed liability limit: $ Statutory $ $ Statutory Aggregate (if applicable) Proposed cash flow protection (if applicable) First Year: $ Second Year: $ Third Year: $ Attach all insurance quotes relating to the above. 3. Provide the following information about the board of trustees (attach additional sheets if necessary). Name of Trustee Company Title or Position 4. Claims Administration Indicate how the applicant's self-insurance claims will be administered: Self administration Third party claims administration If the applicant plans to self-administer its claims, please attach to this application documentation providing information relevant for the bureau's consideration of whether the applicant possesses adequate facilities and competent staff to adjust and service its claims in a manner which would fulfill its obligations under the Workers' Compensation Act, including a resume of at least one person employed by the applicant on a full-time basis with the knowledge and experience to administer claims in accordance with the Workers' Compensation Act. 5. Aggregate Financial Information If the prospective members are private employers, provide the following (calculated according to generally accepted accounting principles): Aggregate working capital $ Aggregate net worth $ Attach a list that provides each member's working capital and net worth. 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-369 REV 09-13 (Page 2) *369* American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document
URL
Embed


Popular Searches

  1. civil case cover sheet
  2. lien
  3. cover sheet
  4. continuance
  5. name change
  6. settlement
  7. modification of child support
  8. Writ of Garnishment
  9. claim of exemption
  10. statement of claim

Bookmark and Share