Self Insurance Guarantee Agreement

<document>COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.STATE OF CONNECTICUTWORKERS' COMPENSATION COMMISSIONCalendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s) WHEREAS (Parent), a corporation organized under the State of,with its principal office located at , on account of financial interest in its subsidiary/division: (Employer), doing business in the State of Connecticut, agrees to assume and unconditionally guarantee to pay all the liabilities and obligations which said Employer may incur as a self-insurer under the provisions of the Connecticut Workers' Compensation Act. It is agreed that should there be a default in payment of any workers' compensation, medical, surgical, financial expenses or assessments that may be awarded against the Employer, the Parent will promptly pay such sums. The Parent agrees that this agreement is for the benefit of each unknown and unnamed employee, or his or her beneficiaries, each of whom may maintain direct action against this agreement for any such amounts which have not been paid by the Employer. The Parent shall have the right to appear and defend in such proceedings, and any award may be entered against the Parent and or the Employer. The Parent will be held responsible for payment of all legal fees incurred by the State, or said employees, in any actions taken to enforce this agreement.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.The insolvency or bankruptcy, or termination of the Employer's status as a self-insurer shall not relieve the Parent of liabilities for injuries sustained during the term of this agreement., one of the Justices of theIt is further agreed that payment made under this agreement shall not affect or be in lieu of any other agreement or bond securing compensation payments executed pursuant to the rules and regulations of the Commission.Court in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Further, the Parent shall notify the Chairman of this Commission of any material change; sale, acquisition, corporate restructure, affecting the Parent or the Employer, not more than 10 business days after the effective date of any change.Attorney(s) forThe Parent shall have the right to terminate this agreement at any time by giving 6o days written notice by certified/registered mail to the Chairman and the Employer. Such cancellation shall not affect liabilities incurred prior to effective date of such cancellation.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.The self-insured status given to the named Employer, which was expressly conditioned on the continued existence of this agreement, shall terminate upon the effective date of any cancellation hereof. This agreement shall automatically cancel upon termination of self-insurer status in the State of Connecticut.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)This agreement shall be binding upon the Parent, its successors, and assigns.This agreement shall be effective as of .Executed this day of 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TONAME OF PARENT COMPANYGREETINGS:signatureWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofprinted nameo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomtitleWitness[SEAL]Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com</document>