DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION 002003002003002003002003This report must be submitted electronically to the Pennsylvania Bureau of Workers222 Compensation002 Self-Insurance Division, in conjunction with the Employer222s Initial Application for Self-Insurance.002 037 American LegalNet, Inc. www.FormsWorkFlow.com 003 003037Please State Incidence Rate: Please State your Injury and Illness Rate Using the FORMULA in the Instructions: 003003003002003002003002003002003002003*221I*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com -- American LegalNet, Inc. www.FormsWorkFlow.com 002003As part of its application for individual self-insurance status submitted to the bureau, an applicant for individual self-insurance status shall provide the bureau with detailed information on its accident and illness prevention program. As part of the process of granting individual self-insurance status, the bureau will use this information to determine whether to grant individual self-insurance status. 037 American LegalNet, Inc. www.FormsWorkFlow.com 003 003 003 003 003 003 003 003 003 003 003 003 003 003 American LegalNet, Inc. www.FormsWorkFlow.com 003 003 003 003 003 003 (xi)003 Other protocols: Determined to be necessary for the protection of employees from injury and illness while in the employer222s employment based on the type(s) of operation(s), workplace and work environments. American LegalNet, Inc. www.FormsWorkFlow.com LIBC-221 REV 10-18 (Page 7) American LegalNet, Inc. www.FormsWorkFlow.com LIBC-221 REV 10-18 (Page 8) Pennsylvania Work Injuries and Illnesses American LegalNet, Inc. www.FormsWorkFlow.com