DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION COMMONWEALTH OF PENNSYLVANIA002 INSURER222S INITIAL REPORT OF 002ACCIDENT & ILLNESS PREVENTION 002SERVICES002 This report must be included with the application for licensure to write002 Workers222 Compensation in the Commonwealth of Pennsylvania.002 An entry must be made for each question. Use N/A or zero when appropriate. (Before completing, please refer to the accompanying instructions. Please print or type all information.) Please note: this form may NOT be altered in any way Report for Application Year 20 FEIN: NAIC: I. Insurer Name: (Please see instructions on Page 4) II. Mailing Address: (Street, P.O. Box, City, State, and Zip Code) III. Is the Insurer prepared to notify policyholders of the availability of accident & illness prevention services? Yes 002003No American LegalNet, Inc. www.FormsWorkFlow.com 002003VI. Check (X) the types of accident & illness prevention services that will be made available and/or provided under Column I, and then check whether they will be made available and/or provided by 002003COLUMN I COLUMN II Insurer222s Providers a. On-Site Surveys c. Accident Cause Analysis h. Pre-Operational Process Reviews i. Policyholder Program Review j. Other [Explain 226 Identify as Item IV (j) on additional sheets] COLUMN III002 Contracted002 Providers002 VII. Indicate the types of accident & illness prevention materials to be provided to policyholders: [check (x) all that apply]: a. Audiovisual Material f. Sample Programs b. Poster/Payroll Stuffers g. Awards c. Booklets, Brochures, Pamphlets h. Other d. Regulations/Standards VIII. Which of the following method(s) will be used to determine the effectiveness of the accident & illness prevention services. [check (x) the method(s) to be used]: a. Incidence Rate Comparison b. Recommendations Closed g. Other d. Satisfaction Surveys LIBC-211I 06-18 (Page 2) (over) American LegalNet, Inc. www.FormsWorkFlow.com NOTE: The following mustcompletely, signed and dated. I, the undersigned, verify that the facts set forth in this report and any attachments are true and correct. Crimes Code002003Signature Date (Please attach additional sheets, where necessary, labeled with appropriate form, section number and letter) Send this Completed Report along with other application package material to: Cressinda E. Bybee Pennsylvania Insurance Department 002002002cbybee@pa.gov LIBC-211I 06-18 (Page 3) (over) American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Form LIBC-211I 002INSURER222S INITIAL REPORT OF ACCIDENT & ILLNESS PREVENTION PROGRAM002 mustmay not be altered. 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 Loss Control Program. Commissioners number assigned to your organization. ITEM 1: Provide the full name of the insurance carrier. A separate report is required for each company applying for a license for Workers222 Compensation authority from the Pennsylvania Insurance Department. ITEM 2: Provide the complete mailing address of the Insurance Carrier. ITEM 3: If the insurer has a prepared Policyholder Notice of availability of Accident & Illness Prevention Services, 223YES(The Pennsylvania Workers222 Compensation Act10 point bold print delivered or issued for delivery in the Commonwealth224. If 223NO224 is checked, you must indicate when the ITEM 4: Mark with a (x) the method(s) to be utilized for determining Policyholder Accident & Illness Prevention Service(s) commitments. Method(s) could include, but not be limited to: (a) policyholder request; (b) loss history; (c) loss ratio (incurred losses/earned premium); (d) incurred losses; (e) paid losses; (f) request by underwriters as a component of coverage; (g) policyholder request; (h) request by brokers as factor developed by the Pennsylvania Compensation Rating Bureau that apportions the cost of workers222 ITEM 5: determine Policyholders Accident & Illness Prevention Service(s) needs. If 223NO224 is checked, you must attach an explanation as to how you will determine policyholder Accident & Illness Prevention Service(s) needs. ITEM 6: Mark with a (x) under Column I, the types of Accident & Illness Prevention Services that you are in a position to Maintain or Provide under the 223SERVICE224 heading are the minimal that an Insurer must be in a position to maintain or provide for Policyholders as a prerequisite for a license to write Workers222 Compensation Insurance within this ITEM 7: Mark with a (x) the type(s) of Accident & Illness Prevention material(s) that will be provided to policyholders. ITEM 8: Mark with a (x) the internal method(s) to be utilized in determining the effectiveness of Accident & Illness Prevention Service(s). Methods could include, but are not limited to: (a) comparisons of incidence rates as calculated by the policyholder or insurer; (b) submitted recommendations that are considered closed; (Please attach additional sheets, where necessary, labeled with the appropriate form, section number and letter.) Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 LIBC-211I 06-18 (Page 4) American LegalNet, Inc. www.FormsWorkFlow.com