Supplemental Information Addendum To Group Self-Insurance Fund Annual Report {LIBC-365} | Pdf Fpdf Docx | Pennsylvania

 Pennsylvania   Workers Comp 
Supplemental Information Addendum To Group Self-Insurance Fund Annual Report {LIBC-365} | Pdf Fpdf Docx | Pennsylvania

Last updated: 2/6/2025

Supplemental Information Addendum To Group Self-Insurance Fund Annual Report {LIBC-365}

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Description

LIBC-365 - SUPPLEMENTAL INFORMATION ADDENDUM TO GROUP SELF-INSURANCE FUND ANNUAL REPORT. This form is used by group self-insurance funds in Pennsylvania to provide supplemental information for their annual report to the Bureau of Workers’ Compensation, Department of Labor & Industry. It includes details about the fund’s administration, fiscal agent, excess insurance coverage, fidelity insurance coverage, and the board of trustees. The fund also acknowledges its commitment to comply with the Workers’ Compensation Act and its regulations. The form must be signed by an officer of the board of trustees and submitted within five months after the end of the fund year to ensure the fund continues to qualify to operate. www.FormsWorkflow.com

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