Form Si-11 - Indemnity Agreement printable pdf download

STATE OF FLORIDA

Division of Workers' Compensation

SELF-INSURANCE SECTION

INDEMNITY AGREEMENT

This indenture made and entered into this _______________day of ______________________, 20_____,

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, 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 4L-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 4L-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:

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

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.

2. The members of the Group do jointly and severally covenant and agree that they will pay any

such award as would otherwise be a claim against the aforesaid surety bond or securities as soon as

the same shall become payable under the laws of the State of Florida, and the Group agrees to pay

the Division, for the administration of the law, such assessments as may be ordered by said Division in

accordance with Sections 440.29, 440.49 and 440.51, Florida Statutes.

Form SI-11 (Rev. 9/96)

Form Si-11 - Indemnity Agreement

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