Group Self-Insurance Fund Member Annual Contribution Worksheet Form {LIBC-350}

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION GROUP SELF-INSURANCE FUND MEMBER ANNUAL CONTRIBUTION WORKSHEET FORM Group fund bureau identification number Group fund name: For fund year beginning: Member federal identification number: Member name: Loss cost rates are: Rating organization filed loss costs Deviated rating organization loss costs approved by Bureau of Workers' Compensation PCRB PAYROLL CLASSIFICATION CODE (IF APPLICABLE) PAYROLL/$100 (OR OTHER BASIS OF CONTRIBUTION) LOSS COST RATE and ending: CLASS DESCRIPTION LOSS CONTRIBUTION Unmodified annual loss contribution (total of loss contributions): Member experience modification factor: Experience modified annual loss contribution (unmodified annual loss contribution X experience modification factor): Loss cost multiplier approved by the bureau: Derived Contribution (experience modified annual loss contribution X loss cost multiplier): Credits Safety Committee Certification (5 percent discount; available to a member with a Safety Committee certified under section 1002 of the W.C. Act in a group using rating organization filed loss costs.): Other discounts (describe): Additional Charges: Other charge (describe): Other charge (describe): Other charge (describe): Estimated Annual Contribution: (derived contribution + charges - credits) 25 percent Minimum Contribution: Employer Information Services 717.772.3702 Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447 Hearing Impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991 Email ra-li-bwc-helpline@pa.gov Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-350 REV 09-13 American LegalNet, Inc. www.FormsWorkFlow.com *350*