Supplemental Information Addendum To Group Workers Compensation Fund {LIBC-368}

LIBC-368 -- SUPPLEMENTAL INFORMATION ADDENDUM TO APPLICATION FOR MEMBERSHIP IN A GROUP WORKERS’ COMPENSATION FUND. This form is used by the Pennsylvania Department of Labor & Industry, Bureau of Workers' Compensation by businesses applying for membership in a group workers' compensation fund and requests detailed information about the business, including its name, address, telephone number, years of operation in Pennsylvania, and information about its business locations and subsidiaries. The form also includes attestations and acknowledgments by the member-applicant, confirming the accuracy of the information provided, agreeing to abide by the provisions of the Workers' Compensation Act and the Pennsylvania Occupational Disease Act, assuming liability for obligations and expenses of the fund, and agreeing to be bound by the terms of the fund's trust agreement. www.FormsWorkflow.com