Supplemental Information Addendum To Annual Report Of Runoff Group Self-Insurance Fund {LIBC-371} | Pdf Fpdf Docx | Pennsylvania

 Pennsylvania /  Workers Comp /
Supplemental Information Addendum To Annual Report Of Runoff Group Self-Insurance Fund {LIBC-371} | Pdf Fpdf Docx | Pennsylvania

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

This is a Pennsylvania form that can be used for Workers Comp.

Alternate TextLast updated: 6/14/2018

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DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION SUPPLEMENTAL INFORMATION002 ADDENDUM TO ANNUAL REPORT002 OF RUNOFF GROUP002 SELF-INSURANCE FUND002 FUND ADMINISTRATOR Company name Contact person Address Address City/Town State ZIP Telephone Email APPLICATION CONTACT (if different from Fund Administrator) Company name Contact person Address Address City/Town State ZIP Telephone Email FISCAL AGENT (if different from Fund Administrator) Company name Contact person Address Address City/Town State ZIP Telephone Email 1.Provide the following information about all companies, except the claims service company, which will be providingservices 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 Email ra-li-bwc-helpline@pa.gov *371* Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com

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