Last updated: 10/1/2014
Group Self Insured Indemnity Agreement {1866}
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Description
Group Self-Insured Indemnity Agreement Workers' Compensation Division This agreement is pre-requisite to becoming a member of: , a self-insured employer group, and is to affirm the joint and several obligations of the undersigned. Effective date , I (We) unconditionally agree to be jointly and severally liable for the payment of any compensation due a subject worker and other amounts due a subject worker and other amounts due to the Oregon Workers' Compensation Division under ORS 656 incurred by a member of the group. Further, I (We) understand and agree that should I (We) terminate from the group that I (We) will continue to be jointly and severally liable for the payment of any compensation due a subject worker and other amounts due the Workers' Compensation Division when such compensation and other amounts arise out of a period when I (We) was (were) a member(s) of the group. It is further understood and agreed that if an order is issued by the Workers' Compensation Division declaring the group to be in noncompliance under the provision of ORS 656.017, that I (We) shall be jointly and severally liable for any civil penalties assessed under ORS 656.735 and any claim costs incurred under ORS 656.054. Signature Date Print name and title Legal name of group member Signature Date Print name and title Legal name of group member Signature Date Print name and title of trust administrator 440-1866 (11/12/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com
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