Common Contracts
1 similar Self-Insurance Agreement contracts
Agreement and Undertaking U.S. Department of LaborSelf-Insurance Agreement • December 23rd, 2016
Authorization of an employer to be self-insured under the Longshore and Harbor Workers' Compensation Act, 33 USC901-950, 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. Please submit the completed form to: US Department of Labor, Office of Workers' Compensation Programs, Division of Longshore and Harbor Workers' Compensation, Room S-3229, 200 Constitution Avenue, N.W., Washington, D.C. 20210. OMB No. 1240-0005Exp. Date: 07/31/2023 Self-Insurer's Name and Address (Principal Office) Sequence #: EIN: Coverage UnderLongshore and Harbor Workers' Compensation Act (33 USC 901)Defense Base Act (42 USC1651)Outer Continental Shelf Lands Act(43 USC1331)Non
