DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION INSURER222S ANNUAL REPORT 002OF ACCIDENT & ILLNESS 002PREVENTION SERVICES002 This report must be submitted to the Pennsylvania Department of Labor and Industry, Bureau of Workers222 Compensation no later than JUNE 01 of each calendar year.Report for calendar year 20 An entry must be made for each question. Use an N/A or zero when appropriate. Before completing please refer to attached instructions for completion of report. National Association of Insurance Commissioners Code Please make necessary corrections to name & mailing address under item #1b. **Please print or type all information 1a. Insurer222s Name and Address 1b. Corrected Name and Mailing Address (if necessary): Insurer Name Address (line 1) Address (line 2) City State Zip 1c. Mark only one report type with an (x) Direct Writers of Workers222 Compensation should complete the remainder of this form and return it to the Bureau.Licensed, but have not written Workers222 Compensation should stop here, sign the form on page 1, completethe section and return it to the Bureau. 1c of the Instructions for completing this report)American LegalNet, Inc. www.FormsWorkFlow.com 2.Total Number of Workers222 Compensation3.Total Written Direct Premiums: (Round toPolicyholders in PA:nearest dollar) $(If there were no services provided, enter a zero in a, b, or c)Services (Round to the nearest dollar)002$002 Prevention Services Received:002(If no requests were received, enter zero)002 Services required by Article X accompany each Workers222 Compensation Insurance policy delivered or issued? Prevention Services which exceed such expensesincluded in a Policyholder222s standard premium.YesYesYes[Mark with an (x) all that apply]:a. Policyholder Requestb. Loss Historyc. Loss Ratio d. Incurred Lossese. Paid Lossesf. Underwriter Requestg. Broker RequestLIBC-210I 0-1 (Page 2) (over) American LegalNet, Inc. www.FormsWorkFlow.com maintained or provided for policyholders. In Column II indicate the number of each service provided during period covered by this report. Number of Each Service Service Provided b. Analysis of Accident Causes d. Industrial Hygiene Services e. Industrial Health Services g. Consultations i. Safety Committee Training 12.What method(s) is/are used to determine the effectiveness and accomplishments of your accidentand illness prevention services? [Mark with an (x) all that apply.]a. Incidence Ratee. Loss Ratiob. Recommendations Closedf. Experience Modc. Incurred Losses d. Satisfaction Surveys LIBC-210I 0-1 (Page 3) (over) American LegalNet, Inc. www.FormsWorkFlow.com 13.Contact PersonQuestions regarding this Annual Report will be directed to the signator unless a contact person isdesignated below.First Name M.I. Last Name Email Address Title Address (line 1) Address (line 2) City State Zip TelephoneExtension Fax LIBC-210I 0-1 (Page 4) (over) American LegalNet, Inc. www.FormsWorkFlow.com PROVIDER VERIFICATION Provide the full name, hiring status and credential code for each individual. Indicate if status is orprovided Accident and Illness Prevention service during the reporting period covered by this annual report. (See instructions) (Mr. Mrs. Ms.) First Name MI Last Name E Credential or Experience or Employee Contracted002 Code Provider was granted002 (Mr. Mrs. Ms.) Credential Code First Name E or Experience or Provider MI was granted Last Name Employee Contracted (Mr. Mrs. Ms.) Credential Code First Name E or Experience or Provider MI was granted Last Name Employee Contracted (Mr. Mrs. Ms.) Credential Code First Name E or Experience or Provider MI was granted Last Name Employee Contracted (Mr. Mrs. Ms.) Credential Code First Name E or Experience or Provider MI was granted Last Name Employee Contracted (Mr. Mrs. Ms.) Credential Code First Name E or Experience or Provider MI was granted Last Name Employee Contracted (Mr. Mrs. Ms.) Credential Code First Name E or Experience or Provider MI was granted Last Name Employee Contracted LIBC-210I 0-1 (Page 5) (over) American LegalNet, Inc. www.FormsWorkFlow.com 002003PROVIDER VERIFICATION Provide the full name, hiring status and credential code for each individual. Indicate if status is orprovided Accident and Illness Prevention service during the reporting period covered by this annual report. (See instructions) (Mr. Mrs. Ms.) First Name MI Last Name E Credential or Experience or Employee Contracted002 Code Provider was granted002 (Mr. Mrs. Ms.) Credential Code First Name E or Experience or Provider MI was granted Last Name Employee Contracted (Mr. Mrs. Ms.) Credential Code First Name E or Experience or Provider MI was granted Last Name Employee Contracted (Mr. Mrs. Ms.) Credential Code First Name E or Experience or Provider MI was granted Last Name Employee Contracted (Mr. Mrs. Ms.) Credential Code First Name E or Experience or Provider MI was granted Last Name Employee Contracted (Mr. Mrs. Ms.) Credential Code First Name E or Experience or Provider MI was granted Last Name Employee Contracted (Mr. Mrs. Ms.) Credential Code First Name E or Experience or Provider MI was granted Last Name Employee Contracted NOTE: PLEASE PHOTOCOPY THIS PAGE FOR ADDITIONAL SERVICE PROVIDERS (Please attach after page 6 of this form) LIBC-210I 0-1 (Page 6) (over) American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR INDIVIDUAL SERVICE PROVIDER IN-SERVICE STATUS002 003 possess a current approved designation and that (Mr. Mrs. Ms.) First Name003 MI Last Name Is service provider an Employee? or contracted? Month Day Year 003 Name of provider: (Mr. Mrs. Ms.) First Name MI Last Name Recognized Provider designation E Credential Code Experience Employee Contracted NOTE: PLEASE PHOTOCOPY THIS PAGE FOR ADDITIONAL IN-SERVICE REQUESTS002 (Please attach after page 7 of this form)002 Send the Completed Individual Insurer Employers 002Accident & Illness Prevention Program Annual Report (LIBC-210-I) to:002 Health & Safety Division002 Audit & Report Processing Section002 002003002003002003 LIBC-210I 0-1 (Page 7) 003 (over) American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Form LIBC-210I Department of Labor and Industry, Bureau of Workers222 Compensation, Health and Safety Division for the preceding calendar year by June 1 of the following year for each Carrier which has been granted a license to write workers222 compensation insurance within the Commonwealth of Pennsylvania. A calendar year is considered as that period from January 1 through December 31 of the Report year. If a Direct Writer, NAIC (Bureau Code/Insurance Carrier Code) Enter the National Association of Insurance Commissioners Code (NAIC) number assigned to you. ITEM 1a: The full name and address of the insurance carrier as registered with the Commonwealth ITEM 1b: Provide any corrections to the insurer222s name and/or mailing address as it appears in 1a in the spaces provided. ITEM 1c: Check the appropriate box corresponding with the Insurer222s status. (Direct Writer, Licensed, but have not written Workers222 Compensation, or Reinsurer or Excess Carrier). never written a Workers222 Compensation policy since being granted a license to write Workers222 Compensation. has ceased writing Workers222 Compensation policies and no longer has any policyholders. NOTE: You are required to attach an explanation informing the Department as to the status of policyholder Accident & Illness Prevention Services, if your Insurer Status on your previous Annual Report was reported as 223Direct Writer224 and your current reporting status is other than 223Direct Writer224 ITEM 2: Indicate the total number of workers222 compensation policyholders for whom coverage was provided within the Commonwealth of Pennsylvania, during the period covered by this report. State the total written direct premiums on direct business as reported on Special Schedule Wrounded to the nearest dollar. Indicate the number of policyholders within each premium size category that received services during the period covered by this report. If no services were provided for a premium size category, indicate by entering a zero. period covered by this report, rounded to the n