00 DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION 002002002003Report LIBC-220E is to be returned to the address on page 12 by the day of , 20 . ELECTRONIC FILING AVAILABLE! Faster and Easier to use! See enclosure for more information mustPlease legibly or type all information. 1. Employer Name and Address 2. Corrected Name and Mailing Address (if necessary): Employer Name Address (line 1) Address (line 2) City State Zip - 3. Number of Physical Locations 4. Total Number of Employees at all Within the Commonwealth of Pennsylvania: Pennsylvania Physical Locations: LIBC-220E REV 11-18 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com 5.003 Accident & Illness Prevention Program (check all that are included in A&IP Program) NOTE: Items (1) through (15) are considered to be basic to any Accident and Illness Prevention Program and shall be included in the Accident & Illness Prevention Program. The A&IP Program must include Program elements 1 226 15 and in place as a pre-requisite for self-insurance. Items 16 (i) through (xii) are required when applicable to workplace and worksite environments. [Check all that apply]: 1. 003Safety Policy Statement 15. Method(s) for Determining and Evaluating A&IP Effectiveness 2. 003Designated A&IP Program Coordinator16. Protocol or Standard Operating Procedures, Developing, Implementing, and Evaluatingwhen applicable to the Workplace the A&IP Program Environments for: 3. 003Assignment of Responsibilities for i. Electrical and Machine Safeguarding 4. 003A&IP Program Goals and Objectivesii. Personal Protective Equipment 5. 003Methods for Identifying and Evaluating iii. Hearing Conservation Hazards and Developing Corrective Action iv. Sight Conservation for their Mitigationv. Lockout/Tag out Procedure6. 003Industrial Hygiene Surveys vi. Hazardous Material Handling, Storage 7. 003Industrial Health Servicesand Disposal Procedures 8. 003A&IP Orientation and Training 9. 003Regularly Reviewed and Updated viii. Fire Prevention and Control Practices Emergency Action Planix. Substance Abuse Awareness and Program10. Employee A&IP Suggestion and Prevention Policies and Programs Communication Programsx. Control of Exposure to Bloodborne11. A&IP Program Employee Involvement PathogensMethods xi. Pre-operational Process Review 12. Established Safety Rules and methods for xii. Other. Other protocols as may betheir Enforcement appropriate for the individual self-insured 13. Methods for Accident Investigation, employer222s operations.* Reporting and Record Keeping *Note: If you checked 223Other224 attach additional 14. Prompt Availability of First Aid, CPR, and sheets describing protocols. Must beOther Emergency Treatments003 6.003 Check the boxes of the methods used to determine the effectiveness of the Accident & Illness Prevention Program. PRIOR FISCAL YEAR I. OSHA/BLS incidence rate comparison related to your Employer North American Industry 002003002003 Incidence Rate Represents: 002 Injuries & Illnesses:002 Total Recordable Cases002 Total cases with days away from work; job transfer or restriction002 Cases with or without job transfer or restriction002 Cases with job transfer or restriction002 Other recordable cases002 Please state your incidence rate: II. Comparison of Statistics Derived from "First Reports"002 Please state your injury and illness rate:002 LIBC-220E REV 11-18 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com 002003002003IV. Loss Ratio002 Please state your loss ratio:002 V. Other: ONE YEAR PRIOR TO LAST FISCAL YEAR I. OSHA/BLS incidence rate comparison related to your Employer North American Industry 002003002003 Incidence Rate Represents: 002 Injuries & Illnesses:002 Total Recordable Cases002 Total cases with days away from work; job transfer or restriction002 Cases with or without job transfer or restriction002 Cases with job transfer or restriction002 Other recordable cases002 Please state your incidence rate:002 II. Comparison of Statistics Derived from "First Reports"002 Please state your injury and illness rate:002 002003002003IV. Loss Ratio002 Please state your loss ratio:002 V. Other: TWO YEARS PRIOR TO LAST FISCAL YEAR I. OSHA/BLS incidence rate comparison related to your Employer North American Industry 002003002003Incidence Rate Represents: 002 Injuries & Illnesses:002 Total Recordable Cases002 Total cases with days away from work; job transfer or restriction002 Cases with or without job transfer or restriction002 Cases with job transfer or restriction002 Other recordable cases002 Please state your incidence rate:002 II. Comparison of Statistics Derived from "First Reports"002 Please state your injury and illness rate:002 002003002003IV. Loss Ratio002 Please state your loss ratio:002 V. Other: LIBC-220E REV 11-18 (Page 3) American LegalNet, Inc. www.FormsWorkFlow.com Provide the full name, hiring status and credential code for each individual. If the Provider does not have a credential code you must provide whether the provider has 223In-Service224 recognition or is recognize based on 223Experience224 for Accident & Illness Prevention Service Providers who provided Accident and Illness Prevention services during the reporting periods covered by this annual report. (see instructions) Use the following page to add additional Providers. (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E LIBC-220E REV 11-18 (Page 4) American LegalNet, Inc. www.FormsWorkFlow.com (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E (Mr.Mrs.Ms.) First Middle Last Name Credential Code or Experience Provider # or In-Service Provider Date In-Service was granted Employee Contracted E Photocopy this page for additional requests. LIBC-220E REV 11-18 (Page 5) American LegalNet, Inc. www.FormsWorkFlow.com 8a. Accident & Illness Prevention Service provider(s) information: 002003Please print or type the following information for all employees and/or contracted personnel that you are requesting In-Service for who possess a approved designation and that have not previously been granted 223In-Service224 status. (Mr.Mrs.Ms.) First Middle Last Name Is service provider an employee? or contracted? What is the date the above service provider began provid