LS-275-SI Agreement and Undertaking (Self-Insured Employer)

Agreement and Undertaking
(Self-Insured Employer)
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U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Division of Longshore and Harbor Workers' Compensation

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).

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OMB No. 1215-0204
Exp. Date: 06/30/2007

Note: persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number.
Coverage Under
Self-Insurer's Name and Address (Principal Office)
Longshore and Harbor Workers'
Compensation Act (33 USC 901)
Defense Base Act
(42 USC 1651)
Outer Continental Shelf Lands Ac
(43 USC 1331)
Type of Business
Nonappropriated Fund Instrumentalities
Act (5 USC 8171)

Having applied for and received authorization from the Office of Workers' Compensation Programs (OWCP) to self-insure our liabilities under the statutes
indicated above, WE UNDERTAKE AND AGREE TO THE FOLLOWING CONDITIONS ON OUR AUTHORIZATION TO SELF-INSURE:
1. We grant to OWCP a security interest in the collateral described below to secure our liability for payment of all compensation, medical services and supplies,
and any other obligations due under the Longshore and Harbor Workers' Compensation Act, 33 USC 901-950, and its extensions.
Amount of Indemnity Bond $

Name of Surety Company

Amount of Letter of Credit $

Name of Financial Institution

Total Value of Securities
Deposited

Where Deposited
$

Par Value of
Securities
$

Deposit Value of
Securities

Issued By

Rate of
interest

Due Date

Number of
Certificate

$

2. We have delivered the indemnity bonds and letters of credit described in section one to OWCP. We have deposited any negotiable securities described in
section one with a Federal Reserve Bank or the Treasurer of the United States in accordance with 20 CFR 703.306 and 703.307 and make the deposited
securities subject to OWCP's control.
3. In the event we renew, replace or increase this collateral, it will be subject to the terms of this Agreement and Undertaking, including the security interest
granted in section one.
PUBLIC BURDEN STATEMENT
We estimate that it will take an average of 15 minutes to complete this collection of information, including time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these
estimates or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the U.S. Department of Labor,
Division of Longshore and Harbor Workers' Compensation, Room C-4315, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

Form LS-275 (SI)
ApriI2004

(2)

OMB No. 1215-0204
Exp. Date: 06/30/2007

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4. We authorize OWCP to bring suit under any indemnity bond, draw upon any letters of credit or seize any negotiable securities, collect the interest and
principal, and sell or otherwise liquidate the negotiable securities or any part thereof, when, in OWCP's opinion we a) Default on any of our obligations under the Longshore and Harbor Workers' Compensation Act or its extensions;
b) Fail to renew any deposited letter of credit or substitute acceptable securities in its place;
c) Fail to renew any deposited negotiable securities at maturity or substitute acceptable securities in their place; or
d) Fail to comply with any of the terms of this Agreement and Undertaking.
5. This agreement incorporates the regulations governing self-insurers and their deposit of security promulgated by the Department of Labor, including any
modifications the Department makes from time to time. We agree to comply with these regulations.
6. If required by OWCP, we will obtain and maintain excess or catastrophic insurance in amounts determined by OWCP.
7. We will comply with OWCP's orders requiring deposits of additional security, proof and verification of our financial condition, statements of our accident and
occupational disease experience, statements of our payroll and any other orders concerning our authorization to self-insure within the time specified in any
notice OWCP delivers to us at our last reported mailing address.
8. If we fail to comply with any applicable statutory or regulatory provision, the terms of this Agreement and Undertaking, or any lawful order or communication
from OWCP, we consent to have OWCP suspend or withdraw our authority to self-insure the payment of compensation under the Longshore and Harbor
Workers' Compensation Act and its extensions.
Signed at
this

day of

20
By

IF THE EMPLOYER IS A CORPORATION USE THIS FORM OF ACKNOWLEDGEMENT
STATE OF

County of
day of

On the

in the year

; before me personally came

, to me known, or being by me duly sworn did depose and say that he/she
resides in

; that he/she is the

(President or other Officer)
of
the corporation described in and which executed the
above instrument; that he/she knows the seal of said corporation, that the seal affixed to said instrument is such corporate seal; that it was so
affixed by order of the Board of Directors of said corporation and that he/she signed his/her name thereto by like authority.

Notary Public (SEAL)
IF THE EMPLOYER IS AN INDIVIDUAL USE THIS FORM OF ACKNOWLEDGEMENT
STATE OF

County of

On the

in the year

day of

; before me personally came

, to me known and known to me to be the person described in and who
executed the above instrument and acknowledged to me that he/she executed the same.

Notary Public (SEAL)
IF THE EMPLOYER IS A PARTNERSHIP USE THIS FORM OF ACKNOWLEDGEMENT
STATE OF
On the

County of
day of

in the year

; before me personally came

, described on the foregoing instrument to me known and known to me to
be a member of the said firm and the person who executed said instrument and acknowledged to me that he/she executed the same on behalf of said
firm.

Notary Public (SEAL)
Form LS-275 (SI)
ApriI 2004