DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION ANNUAL REPORT OF 002ACCIDENT & ILLNESS PREVENTION002 PROGRAM STATUS BY GROUP 002SELF-INSURANCE FUNDS002 For fund year To -- -- MM DD YYYY MM DD YYYY Insurer code Form must be completed in its entirety! Please make necessary corrections to Item #1a in Item 1b 1a. Fund name and address Fund name Address (line 1) Address (line 2) City State ZIP - 1b. Corrected Name and Mailing Address (if necessary): Fund name Address (line 1) Address (line 2) City State ZIP - 2a. Total Number of Members 2b. Total Number of Members 2c. Total Amount Spent on $002 If 3a is less than 3b, please attach an explanation labeled item 3. LIBC-230G REV 10-18 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com a. Member Contribution (%) f. Incurred Losses 003003003 003 003 003003 002003002003002003003003003003003003003Suggestion and Communications Program. Storage and Disposal Procedures. 003003003003002003002003003003003003003003002002003002003003 003e. Sample Forms003 Materials $ LIBC-230G REV 10-18 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com 003003 002003 002003 Total recordable cases 002003002003002003002003 Please state your incidence rates for: 002003002003002003. . . 003003 002003002003. . . 003002003002003. . . 003003 002003002003. . . 003003 LIBC-230G REV 10-18 (Page 3) American LegalNet, Inc. www.FormsWorkFlow.com PROVIDER VERIFICATION does not mustor is (see instructions (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E LIBC-230G REV 10-18 (Page 4) American LegalNet, Inc. www.FormsWorkFlow.com 002003 (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E (Mr. Mrs. Ms.) First Middle Last name Credential code oror E LIBC-230G REV 10-18 (Page 5) American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR INDIVIDUAL SERVICE PROVIDER IN-SERVICE STATUS do not possess a current (Mr. Mrs. Ms.) First 003M.I. Last name --MM DD YYYY 003003(Mr. Mrs. Ms.) First 003M.I. Last name LIBC-230G REV 10-18 (Page 6) American LegalNet, Inc. www.FormsWorkFlow.com 003003only if different from authorized signatory in item Section 12. QuestionsFirst name 003M.I. Last name Address (line 1) Address (line 2) City State ZIP - -- -- 12. Signatory Information -The following MUSTentirety, signed and dated. The signature must be original and not photocopied or stamped. First name M.I. Last name Address (line 1) Address (line 2) City 003State ZIP - -- -- I, the undersigned, verify that the facts set forth in this report and any attachments are true and assumes ultimate responsibility of the accuracy of responses contained herein. Signature003 Date 002003002003002003002003002003717.772.1636 *230G* Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal opportunity Employer/Program002 LIBC-230G REV 10-18 (Page 7) American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Form LIBC-230G NOTE: The term Accident & Illness Prevention Services as described in the Pennsylvania Workers222 Compensation Act is synonymous with the terms Safety and Health Program, and . ITEM 1a: ITEM 1b: submission of your last group self-insurance fund annual report. ITEM 2a: ITEM 2b: Fund Year. ITEM 2c: ITEM 3a: ITEM 3b: ITEM 3c: ITEM 4: of employees ITEM 5: inspections performed. LIBC-230G REV 10-18 (Page 8) American LegalNet, Inc. www.FormsWorkFlow.com ITEM 6:003 (1)003 Safety Policy Statement(2)003 (3)003 : responsibilities must be documented. (4)003 (5)003 (6)003 : A documented (7)003 (8)003 : (9)003 : (10)003 (11)003 (12)003 : LIBC-230G REV 10-18 (Page 9) American LegalNet, Inc. www.FormsWorkFlow.com (13)003 : 003003(i)003 (ii)003 (iii)003 003003: A procedure consisting of controls and employee training to 003003003003003003003003003003003003LIBC-230G REV 10-18 (Page 10) American LegalNet, Inc. www.FormsWorkFlow.com 003003ITEM 7:003 ITEM 8:003 Section I: number of recordable injuries x 200,000 divided by hours workedOR Section II: Employer222s Report of Occupational Injury or Diseasenumber of employeesOR Section III: OR Section IV: OR Section V: ITEM 9:003 OROR OR OR AND Note: New requests for 223In-Service224 Provider status can be made by completing sections 10 a. and 10b. LIBC-230G REV 10-18 (Page 11) American LegalNet, Inc. www.FormsWorkFlow.com .003003003003003003003003003003003003003003003003003003003003003003003003003003003003003003003003003003003003003003INDUSTRY-SPECIFIC QUALIFICATIONS: Institute (NATMI). Institute (NATMI). 003003003003003003003003LIBC-230G REV 10-18 (Page 12) American LegalNet, Inc. www.FormsWorkFlow.com In-Service Status:notis obtained. New requests for In-Service Status ITEM 10a: This date should be the date the individual began employment in the Accident & Illness Prevention Field. ITEM 10b: ITEM 11: authorized Signatory. ITEM 12: Signatory Information. This report mustoriginal number, of the person signing the report, and the date the report is signed. The company or corporation assumes ultimate responsibility of the accuracy of responses contained herein. NOTE: Since it may be necessary to clarify information reported, if the person responsible Person Information section should be completed. Bureau contact information: Pennsylvania Bureau of Workers222 Compensation002 Health & Safety Division002 Report Processing & Audit Section002 1171 South Cameron Street, Room 324002 Harrisburg, PA 17104-2501002 717.772.1636002 LIBC-230G REV 10-18 (Page 13) American LegalNet, Inc. www.FormsWorkFlow.com