SELF-INSURANCE AGREEMENTSelf-Insurance Agreement • August 4th, 2014 • Rhode Island
provisions of Chapter 29 through 38, inclusive, of Title 28 of the Rhode Island General Laws, as amended, known as the Worker’s Compensation Act (“the Act”); and
CONTENTSSelf-Insurance Agreement • June 22nd, 2023
ContractSelf-Insurance Agreement • April 26th, 2007
AGREEMENT AND ACKNOWLEDGMENT TO BE ATTACHED TO APPLICATION FOR SELF-INSURANCESelf-Insurance Agreement • July 12th, 1999
Applicant hereby agrees to pay all assessments and to participate in the Assigned Claims Plan provided in the Minnesota No-Fault Automobile Insurance Act.
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
• General Definitions 2 • General Exclusions 5 • A. Insuring Agreement 6 • B. Definitions 6 • C. Exclusions 6 • D. Limits of Insurance 8 • E. Deductibles 9 • F. Conditions for Coverage 9 • G. Reporting Losses 10 • H. Loss Settlement 11 • A. Insuring...Self-Insurance Agreement • March 26th, 2018
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
ContractSelf-Insurance Agreement • April 26th, 2007
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
MACKINAC BRIDGE AUTHORITY (EXCERPT)Self-Insurance Agreement • October 13th, 2021
Sec. 1a. (1) The authority may enter into an agreement with the state transportation department to provide for the self-insurance of bridge assets and activities. The agreement shall set forth the terms and conditions of the self-insurance consistent with this section.
SELF-INSURANCE AGREEMENT CONTINUATION, EXTENSION and/or AMENDMENTSelf-Insurance Agreement • July 30th, 2014
The Agreement in force between , a Rhode Island self-insured and the Rhode Island Department of Labor & Training commencing
