Common Contracts
2 similar Agreement and Undertaking contracts
Agreement and UndertakingAgreement and Undertaking • November 19th, 2022
An insurance carrier's authorization to write insurance for the payment of compensation under the Longshore and Harbor Workers' Compensation Act, 33 USC 901-945, or any of its extensions, may be suspended or revoked if this agreement and undertaking form is not executed and returned to the Office of Workers' Compensation Programs (30 USC 932; 20 C.F.R. 703.213) on request and/or whenever a security deposit is required. The Office will use theinformation collected to assure the carrier's prompt payment of compensation, medical services and supplies, and any other obligations it has under these statutes. OMB No. 1240-0005Exp Date: 11/30/2013 Carrier's Name and Address (Principal Office) Coverage Under Longshore and Harbor Workers' Outer Continental ShelfCompensation Act (33 USC 901) Lands Act (43 USC 1331) Defense Base Act Nonappropriated Fund(42 USC 1651) Instrumentalities ActAct (5 USC 8171)
An insurance carrier's authorization to write insurance for the payment of compensation under the Longshore and Harbor Workers' Compensation Act, 33 USC 901-945, or any of its extensions, may be suspended or revoked if this agreement and undertaking...Agreement and Undertaking • December 23rd, 2016
Having applied for and received authorization from the Office of Workers' Compensation Programs (OWCP) to write insurance under the statutes indicated
