Pennsylvania > Workers Comp

Supplemental Information Addendum To Group Sel-Insurance Fund Annual Report LIBC-365 - Pennsylvania

Supplemental Information Addendum To Group Sel-Insurance Fund Annual Report 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 SUPPLEMENTALINFORMATION ADDENDUMTOGROUP SELF-INSURANCEFUNDANNUALREPORT 1. 2. Name of fund Insurer code FISCAL AGENT Companyname Contactperson Address Address City/TownStateZIP Telephone Email (ifdifferentfromFundAdministrator) FUND ADMINISTRATOR Companyname Contactperson Address Address City/TownStateZIP Telephone Email APPLICATION CONTACT (ifdifferentfromFundAdministrator) Companyname Contactperson Address Address City/TownStateZIP Telephone Email 3. Excess Insurance Provide the following information about the Fund's excess insurance coverage: Specific Retention amount: $ Liability limit: $ Statutory $ $ Statutory Aggregate(if applicable) Cash Flow Protection (if applicable) First Year: $ Second Year: $ Third Year: $ Insurer Policy number Effective period: From - - To - - MMDD YYYY MMDD YYYY LIBC-365 REV 09-13 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com 4. Fidelity Coverage ProvidethefollowinginformationabouttheFund'sfidelityinsurancecoverage: Typeofcoverage Deductible Liabilitylimit $ $ $ $ Insurer Policy number Effective period: From $ $ $ $ - - To - - MMDD YYYY MMDD YYYY 5. Provide the following information about the Board of Trustees Name of Trustee (attach additional sheets if necessary). Company Title or Position 6. Aggregate Financial Information If the members are private employers, provide the following (calculated according to generally accepted accounting principles): Aggregateworkingcapital$ Aggregatenetworth$ Attachalistthatprovideseachmember'sworkingcapitalandnetworth. LIBC-365 REV 09-13 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com ACKNOWLEDGEMENTS AND AGREEMENTS TheundersignedfundhasbeenapprovedtooperateasafundundertheWorkers'CompensationAct.Itacknowledgesthat theabovefactsanddocumentshavebeensubmittedunderoathtotheBureauofWorkers'CompensationoftheDepartment ofLabor&IndustrytoenablethebureautodecideifthefundcontinuestoqualifytooperateasafundundertheAct.This reportmustbesubmittedtothebureaunolaterthanfive(5)monthsfollowingtheendofeachannualfundyear. ThefundherebyconfirmsitsagreementtofairlyadministertheWorkers'CompensationActinaccordancewiththerulesand regulationsoftheDepartmentofLabor&Industryandnotcircumventthelawforthepurposeofavoidingorreducingthe compensation liability. Thefundacknowledgesthatitunderstandsandacceptsthatfollowingthesubmissionofthereportoratothertimes determined by the bureau, the bureau may revise the conditions previously set for the issuance of the fund's permit. The fund'spermitmayberevokediftherevisedconditionsarenotmetinthetimeprescribedbythebureau. ThisreportmustbesignedbyanofficeroftheBoardofTrusteesofthefundandattestedtoassetforthbelow. IverifythatthefactssetforthinthisGroupSelf-InsuranceFundReportaretrueandcorrecttothebestofmyknowledge, informationandbelief.Thisverificationismadesubjecttothepenaltiesof18Pa.C.S.ยง4904,relatingtounswornfalsification to authorities. Datesigned By Signature First name (typed/printed) M - MMDD YYYY Last name Title (typed/printed) Employer Information Services 717.772.3702 Claims Information Services toll-freeinsidePA:800.482.2383 local&outsidePA:717.772.4447 Hearing Impaired toll-freeinsidePATTY:800.362.4228 local&outsidePATTY:717.772.4991 Email ra-li-bwc-helpline@pa.gov *365* Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-365 REV 09-13 (Page 3) American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document
URL
Embed


Popular Searches

  1. Form Interrogatories-General
  2. durable power of attorney
  3. deposition subpoena
  4. bill of costs
  5. Request for entry of default
  6. stipulation of discontinuance
  7. Preliminary Change of Ownership Report
  8. Notice and Acknowledgment of Receipt
  9. Decree of Dissolution of Marriage
  10. proof of service of summons

Bookmark and Share