Supplemental Information Addendum To Application As A Group Workers Compensation Fund {LIBC-369} | Pdf Fpdf Docx | Pennsylvania

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Supplemental Information Addendum To Application As A Group Workers Compensation Fund {LIBC-369} | Pdf Fpdf Docx | Pennsylvania

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

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 APPLICATION002 AS A GROUP WORKERS222002 COMPENSATION FUND002 Name of fund applicant FUND ADMINISTRATOR Contact person Email APPLICATION CONTACT Contact person Contact person Email 1.American LegalNet, Inc. www.FormsWorkFlow.com 2.Excess Insurance 3. 4.Claims Administration0020020035.Aggregate Financial Information002003002003002003 002003 Employer Information Services Claims Information Services Hearing Impaired Email *369*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com

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