Memorandum Of Understanding Between Department Of Labor And Industries And printable pdf download

Memorandum Of Understanding Between Department Of Labor And Industries And

Department of Labor and Industries

Self-Insurance

PO Box 44891

Olympia WA 98504-4891

MEMORANDUM OF UNDERSTANDING

This is a memorandum of understanding between ____________________________________ and

Self-Insured Employer

the Department of Labor and Industries regarding the use of an annuity to secure the pension

obligation of ___________________________________ , ________________________________.

Claimant’s Name

Claim and Folio Numbers

Whereas, ____________________________________ has been certified to self-insure its workers'

Employer’s Name

compensation liabilities under the Industrial Insurance Act of the State of Washington; and,

Whereas, __________________________________________ has sustained an industrial injury or

Claimant’s Name

incurred an occupational disease which has resulted in the creation of a pension obligation whose

current present value is $ ______________________; and,

Whereas, the self-insurer wishes to secure this obligation by purchasing an annuity issued by

___________________________________________;

Insurance Company Name

THEREFORE:

The Self-Insurer and the Department agree as follows:

a) The annuity will be purchased by the self-insurer with the Department being listed as the

beneficiary. A copy of the annuity is to be provided to the Department.

b) The Insurance Company must meet the provisions as specified in RCW 51.44.070 in order to

have its annuity acceptable to the Department.

c) In the event of a default by the annuity provider, the self-insured employer must re-secure the

pension obligation with other acceptable means within forty five days of the default. The self-

insured employer remains liable for reimbursing the Department for the quarterly

reimbursement of benefits.

d) The insurance company should make its payments to the Department by the 20th of the month

following the end of a calendar quarter. The reimbursement should indicate the claimant's

name, claim and folio numbers and the employer's name. A quarterly statement will be sent to

the self-insured employer indicating the amount that would be due from the annuity provider.

e) If the amount of monthly benefits change, the self-insured employer is liable for and must

make up any deficiency or would receive a rebate of any excess of the quarterly

reimbursements on an annual basis. Any adjustments would be determined in an annual

review of the pension obligation.

F207-129-000 memo of understanding 12-92

Memorandum Of Understanding Between Department Of Labor And Industries And