Supplemental Information Addendum To Application As A Group Workers Compensation Fund
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Supplemental Information Addendum To Application As A Group Workers Compensation Fund Form. This is a Pennsylvania form and can be use in Workers Comp.
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Tags: Supplemental Information Addendum To Application As A Group Workers Compensation Fund, LIBC-369, Pennsylvania Workers Comp,
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION SUPPLEMENTAL INFORMATION002 ADDENDUM TO APPLICATION002 AS A GROUP WORKERS222002 COMPENSATION FUND002 Name of fund applicant FUND ADMINISTRATOR Contact person Email APPLICATION CONTACT Contact person Contact person Email 1.American LegalNet, Inc. www.FormsWorkFlow.com 2.Excess Insurance 3. 4.Claims Administration0020020035.Aggregate Financial Information002003002003002003 002003 Employer Information Services Claims Information Services Hearing Impaired Email *369*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com
