Free F207-129-000 memorandum of understanding - Washington


File Size: 57.6 kB
Pages: 2
Date: September 30, 2004
File Format: PDF
State: Washington
Category: Workers Compensation
Author: hilc235
Word Count: 423 Words, 3,129 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lni.wa.gov/Forms/pdf/207129a0.pdf

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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 selfinsured 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.
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f) In the event of a default by both the self-insurer and the annuity provider, pension benefits would be sought from the main surety provider for the self-insurer. g) Legal proceedings initiated by any party with respect to this annuity shall be subject to the courts and laws of the State of Washington. This agreement is effective _____________/________/_________ . Date: __________/________/_________ . Department of Labor and Industries Date: _________/________/_________ . ____________________________________________
Assistant Director of Self-Insurance

___________________________________________
Self-Insurer's Authorized Signature

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