Employers Request To Include Subsidiary Within Self Insurance Program {SI-5}

WORKER'S COMPENSATION BOARD OF INDIANA 402 WEST WASHINGTON STREET, ROOM W196 INDIANAPOLIS, IN 46204-2753 www.in.gov/workcomp FORM SI-5 (Revised 2012) WORKER'S COMPENSATION AND OCCUPATIONAL DISEASES ACTS EMPLOYER'S REQUEST TO INCLUDE A SUBSIDIARY WITHIN ITS SELF-INSURANCE PROGRAM The undersigned, an employer subject to the provisions of the "Indiana Worker's Compensation and Occupational Diseases Acts", hereby requests that a subsidiary be added to its self-insurance program. This subsidiary will remain within the self-insurance program until the parent company requests, in writing, the subsidiary's withdrawal, and that request is approved by the Worker's Compensation Board. This employer, under the penalties of perjury, hereby states the following facts: 1. SELF-INSURED ENTITY _________________________________________ SUBSIDIARY _________________________________________ FEIN ____-___________ FEIN ____-___________ 2. EMPLOYMENT INFORMATION (For Subsidiary) Indiana Location(s) a. b. c. d. e. Kind of Employment # of Employees __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ 3. LOSS HISTORY (Include Subsidiary to be added) Under Amount Paid, please provide the total paid for each category during the calendar year, regardless of the date of the injury. Under # Injuries, please provide the number of injuries which occurred during the calendar year that fell within, or resulted in payments in, each category (regardless of when paid.) Some injuries will be counted in more than one category. American LegalNet, Inc. www.FormsWorkFlow.com If this information is not provided on a calendar year basis, please specify the appropriate dates: _______________ through_________________. 2009 Amount Pd Medical TTD TPD PTD PPI Death Benefits Burial Expenses Settlements First Report of Injury Amputation Prosthetic Device TOTAL # Injuries 2010 Amount Pd # Injuries 2011 Amount Pd # Injuries $ $ $ 4. BOND CALCULATION (a) Determine three-year average of total medical/compensation paid per "Loss History" (Be sure to include the subsidiary) 2009 Total 2010 Total 2011 Total Three-Year Paid Paid + Paid + Total Paid $____________ $____________ $____________ $____________ divided by 3= $___________ 3yr average (b) Multiply 3 year average by 2 (c) Enter total unpaid compensation liability for fatalities (d) Add lines (b) and (c) (e) Enter greater of $500,000 or line (d) $____________ $______________ $____________ $____________ American LegalNet, Inc. www.FormsWorkFlow.com WORKER'S COMPENSATION BOARD OF INDIANA 402 WEST WASHINGTON STREET, ROOM W196 INDIANAPOLIS, IN 46204-2753 www.in.gov/workcomp FORM SI-4 (Revised 2012) INDEMNITY AGREEMENT BY THE PARENT CORPORATION FOR WHOLLY OWNED OR MAJORITY OWNED SUBSIDIARY (Use a separate form for each subsidiary to be indemnified. Do not alter or modify.) KNOW ALL MEN BY THESE PRESENTS, THAT __________________________________ (Name of Parent Company) corporation, organized and existing under and by virtue of the laws of the State of __________________________________________________________ do hereby guarantee payment of the compensation, provided for under the compensation provisions of the Worker's Compensation and Occupational Diseases Acts of the State of Indiana, and in the event that said ___________________________________shall not pay or cause to be direct (Name of Subsidiary) to its employees the compensation due or that may become due under said Acts, then the undersigned parent corporation covenants and agrees that it will pay to all such employees of the named subsidiary such compensation, including a reasonable attorney fee incurred by said employees in any action brought on this agreement, with the express agreement and understanding as a condition precedent to the execution and acceptance of this agreement, that it is, for the benefit of all unknown and unnamed employees of said named subsidiary, and that said employees are hereby empowered and authorized to maintain direct action on this agreement and that the parent corporation does recognize this agreement as a direct financial guarantee to said employees or the dependents of a deceased employee; that the parent corporation shall have a right to cancel and terminate this agreement at any time upon giving the named subsidiary and the Worker's Compensation Board of Indiana at least SIXTY (60) DAYS written notice of its intent to cancel. Such cancellation shall not affect its liability as to any compensation for injuries occurring prior to TEN (10) DAYS after the date of cancellation specified in such notice. PROVIDED HOWEVER, that cancellation of this indemnity agreement shall be allowed only upon the presentation of proof of the financial ability of the subsidiary to pay compensation direct and upon the approval of the Worker's Compensation Board of Indiana. The liability of the parent corporation as a result of this Indemnity Agreement shall not terminate except-upon order of the Board. This agreement shall be effective as of the_____day of________20___. American LegalNet, Inc. www.FormsWorkFlow.com Executed at______________ this________day of_______________ 20________. FOR PARENT CORPORATION: ATTEST: _______________________ Signature ________________________________ Signature of Corporate Secretary _______________________ Printed Name ________________________________ Printed Name _______________________ Title (SEAL) American LegalNet, Inc. www.FormsWorkFlow.com