Common Contracts
1 similar Self-Insurance Agreement contracts
Agreement and Undertaking U.S. Department of LaborSelf-Insurance Agreement • August 7th, 2003
Authorization of an employer to be self-insured under the Longshore and Harbor Workers' Compensation Act, 33 USC 901-950, or any of its extensions, may be denied unless this agreement and undertaking form is executed and returned to the Office of Workers' Compensation Programs. (30 USC 932(a) (2); 20 C.F.R. 703.303, 703.313). The Office will use the information collected to assure the employer's prompt payment of compensation, medical services and supplies, and any other obligations it has under these statutes. Furnishing this information is mandatory. (20 CFR 703.304). Note: persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. OMB No. 1215-0204Exp. Date: 06/30/2007 Self-Insurer's Name and Address (Principal Office) Coverage Under Longshore and Harbor Workers'Compensation Act (33 USC 901)Defense Base Act(42 USC 1651) Outer Continental Shelf Lands Ac(43 USC 1331) Nonappropriated Fund InstrumentalitiesAct (5 USC 81
