Common Contracts
1 similar Self-Insurance Agreement contracts
Agreement and Undertaking U.S. Department of LaborSelf-Insurance Agreement • September 14th, 2021
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 usethe information collected to assure the employer's prompt payment of compensation, medical services and supplies, and any other obligations it has under these statutes. OMB No. 1240-0005Exp. Date: 10/31/2016 Self-Insurer's Name and Address (Principal Office) Coverage Under Longshore and Harbor Workers' Compensation Act (33 USC 901)Defense Base Act (42 USC1651)Outer Continental Shelf Lands Act(43 USC1331)Nonappropriated Fund Instrumentalities Act (5 USC 8171) Type of Business
