Supplemental Information Addendum To Group Workers Compensation Fund Form. This is a Pennsylvania form and can be use in Workers Comp.
Tags: Supplemental Information Addendum To Group Workers Compensation Fund, LIBC-368, Pennsylvania Workers Comp,
0 DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION SUPPLEMENTAL INFORMATION002 ADDENDUM TO APPLICATION FOR002 MEMBERSHIP IN A GROUP002 WORKERS222 COMPENSATION FUND002 1.Name of fund2.Complete legal name of member-applicant3.Mailing address4.003 Telephone5.003 How many years has the member-applicant operated in Pennsylvania?6.003 Provide the following information about all of the member-applicant222s Pennsylvania business locations (attach additionalsheets if necessary).Name/Division Address Number of Employees TOTAL If the member-applicant is a subsidiary of a U.S. parent company, provide the following information: Top U.S. parent name Address City/Town State ZIP Percentage of ownership American LegalNet, Inc. www.FormsWorkFlow.com ATTESTANTS002 The member-applicant hereby attests that the facts set forth in the foregoing application are true; that it has never defaulted on the payment of obligations and liabilities due under the Workers222 Compensation Act and the Pennsylvania Occupational Disease Act as an individual self-insurer; that is has not been found to have violated Section 305 or Section 435 of the Workers222 Compensation Act as an individual self-insurer; and that is has not been delinquent in payment of or cancelled for non-payment of workers222 compensation premiums for a period of at least two years prior to the submission of this application. ACKNOWLEDGEMENTS AND AGREEMENTS In consideration of the approval of this application for membership in a group workers222 compensation fund, the member-applicant hereby expressly agrees as follows: 1.003 To accept and to be bound by the provisions of the Workers222 Compensation Act and the Pennsylvania OccupationalDisease Act and the rules and regulations promulgated under the acts.2.003 To provide to the fund any data, documents or information required by the fund to decide if it meets the fund222s criteriafor membership.3.003 To assume, pay and discharge jointly and severally any liability under the acts of any and all members of the fund andany and all obligations and expenses of the fund incurred during its period of membership. The applicant acknowledgesthat it is liable for all claims incurred during its membership, even after its membership in the fund has terminated. It it was a member, it is liable to pay assessments on those losses. the Department of Labor & Industry.5.003 That these agreements shall be binding upon the member-applicant, its successors and assigns.The member-applicant hereby formally applies for membership in the above-named fund, to be effective 12:01 a.m. , 20 . Name and Title (typed/printed) Employer Information Services 717.772.3702 Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447 Name and Title (typed/printed) Hearing Impaired Email email@example.com *368*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com