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Authorization for employers to self-insure under the Longshore and Harbor Workers' Compensation Act, requiring the execution and return of this form to the Office of Workers' Compensation Programs.

How to fill out agreement and undertaking self-insured

How to fill out Agreement and Undertaking (Self-Insured Employer)

1. Begin by providing your business name and address at the top of the form.
2. Enter the date when you are filling out the agreement.
3. Clearly state your intention to apply for self-insured employer status.
4. Provide details regarding your workers' compensation claim history.
5. Outline your proposed plan for funding and managing workers' compensation claims.
6. Include the necessary financial statements and insurance information.
7. Ensure that all required signatures are included, including that of an authorized representative.
8. Review the document for accuracy and completeness before submission.
9. Submit the completed form to the appropriate regulatory body.

Who needs Agreement and Undertaking (Self-Insured Employer)?

1. Employers who wish to self-insure their workers' compensation liabilities.
2. Businesses that have demonstrated financial stability and are capable of managing claims independently.
3. Organizations with a sufficient claims history to justify self-insurance.

People Also Ask about

What are the disadvantages of self-insured plans?

Self-insurance allows organizations to have more control over coverage, tailor policies to meet their specific needs, and potentially save money on premiums. However, self-insurance also has some disadvantages, including financial risk, administrative burden, and the need to allocate capital to cover potential losses.

What is employer self-insured coverage?

The main difference between the two types of work injury claims is the administration. Explicitly, the Department of Labor and Industries (L&I) manages and administers L&I claims. In contrast, third-party administrators (TPAs), such as Sedewick, administer self-insured employer claims.

Why would a company choose to be self-insured?

Some large businesses may choose to self-insure to save money and control costs for their commercial property, auto and general liability coverages. When a business chooses this route, they don't buy a plan from an insurance company.

What does it mean for a plan to be self-insured?

A self-insured health plan (also known as a self-funded health plan) is coverage offered by an employer or association in which the employer (or association) takes on the risk involved with providing coverage, instead of purchasing coverage from an insurance company.

What is the difference between self-insured and L&I?

Self-insurance involves setting aside your own money to pay for a possible loss instead of purchasing insurance and expecting an insurance company to reimburse you.

What does it mean when your employer is self-insured?

Self-insurance is also called a self-funded plan. This is a type of plan in which an employer takes on most or all of the cost of benefit claims. The insurance company manages the payments, but the employer is the one who pays the claims.

For pdfFiller’s FAQs

What is Agreement and Undertaking (Self-Insured Employer)?

An Agreement and Undertaking (Self-Insured Employer) is a formal document that allows employers to self-insure their workers' compensation liabilities, rather than purchasing insurance from a traditional insurer.

Who is required to file Agreement and Undertaking (Self-Insured Employer)?

Employers who wish to self-insure their workers' compensation claims must file an Agreement and Undertaking with the relevant regulatory authority, demonstrating their financial ability to cover potential claims.

How to fill out Agreement and Undertaking (Self-Insured Employer)?

To fill out the Agreement and Undertaking, employers must provide detailed information about their business, financial status, and ability to manage workers' compensation claims, following the specific guidelines set by the regulatory authority.

What is the purpose of Agreement and Undertaking (Self-Insured Employer)?

The purpose of the Agreement and Undertaking is to ensure that self-insured employers can adequately manage and fund workers' compensation claims, protecting both employees and the financial integrity of the system.

What information must be reported on Agreement and Undertaking (Self-Insured Employer)?

Information required includes the employer's business details, financial statements, loss history, and any other relevant data that establishes the employer's capacity to fulfill its obligations as a self-insured entity.