Les Form Si-11 - Indemnity Agreement

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FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
DIVISION OF WORKERS' COMPENSATION
BUREAU OF OPERATIONS SUPPORT
SELF-INSURANCE SECTION
INDEMNITY AGREEMENT
This indenture made and entered into this __________________ day of __________________,
19_________, by and between all of the parties hereinafter executing the same and jointly and
severally.
WITNESSETH:
WHEREAS, the undersigned persons, firms and corporations hereinafter referred to as the Group,
have applied to the State of Florida Department of Labor and Employment Security Division of
Workers' Compensation, hereinafter referred to as the Division, for authority to become self-insurers,
pursuant to the terms of the Workers' Compensation Law, and specifically as provided by Section
440.57, Florida Statutes, and the Division Rule 38F-5.106, Rules for Self-Insurers, and,
WHEREAS, the Group agrees there is a majority ownership interest between the undersigned
persons, firms and corporations, as required by the said Rule 38F-5.106, and,
WHEREAS, the Division, upon petition of the Group, has made its order approving said application,
but upon the following conditions, to wit:
I.
The Group shall, before being issued a certificate, post a security deposit or bond, as conditioned in
the Rules for Self-Insurers, to secure performance of any awards which might be made against the
Group or any of them:
II.
The Group shall execute a covenant or agreement whereby the Group, and all of them, will jointly
and severally covenant to assume and discharge, by payment, any lawful awards entered under the
provisions of the Workers' Compensation Act against any member of the Group, which awards shall
have been sustained by the courts where an appeal by either party is taken;
AND WHEREAS, the conference assembled, the Group has elected to comply with said conditions
and become self-insured and are now ready to executive the other covenants required;
NOW THEREFORE; for and in consideration of the mutual covenants, promises and obligations
herein contained, which are given to and accepted by the Group and each member thereof to the
other, the parties of this instrument covenant, stipulate and agree as follows:
1. The Group hereby agrees to file with the Division either a corporate surety bond or acceptable
securities in the principal sum of_______________________________________________
dollars ($___________) to secure performance by the Group of payment of all lawful awards
made under the provisions of the Workers' Compensation Act against any member or members
of the Group, arising out of and in the course of such claimant's employment, and which awards
shall have been sustained by the courts where an appeal by either party is taken, and upon
condition that said member through which such claim originates shall not have been suspended
from, resigned from or expelled from the Group after thirty (30) days notice to the Division of
such suspension, resignation or expulsion and which notice to the Division shall have been
given thirty (30) days prior to the accident complained of.
LES Form SI-11 (Rev. 09/96)
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