LONGSHOREHARBORWORKERSANDORinstructionspertaintoInsuranceeachcertificationcompanyregulatoryreportingSectioninformalmechanismsrepresentativeseffortsprofessionalresponsibleAdministratorshouldcompanyapp ID: 886346
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1 REQUIREMENTSFORAUTHORIZATIONINSURED LONG
REQUIREMENTSFORAUTHORIZATIONINSURED LONGSHOREHARBORWORKERS AND/OR instructionspertainto Insurance.each certificationcompanyregulatoryreporting[SectioninformalmechanismsrepresentativeseffortsprofessionalresponsibleAdministratorshouldcompanyapplicationnotificationcorrespondencetherelatedmaterial DepartmentAvenue,N.W. telephoneWorkers’Compensation (2/12) PLEASE TYPE THIS STATEMENT ON PARENT COMPANY LETTERHEAD PARENT COMPANY GUARANTY Guaranty made on (date ) by (parent company ) of (address ) as guarantor of all obligations incurred by (subsidiary company ) of (address ) under the Longshore and Harbor Workers' Compensation Act and/or its extensions, the Outer Continental Shelf Lands Act; the Defense Base Act and the Nonappropriated Fund In consideration of the granting of self-insurance authorityunder the Longshore and Harbor Workers' Compensation Act and/or ), (parent company ) unequivocally guarantees the payment of all obligations incurred by (subsidiary company ) under the Longshore and Harbor Workers' Co
2 mpensation Act and/or its extensions, th
mpensation Act and/or its extensions, the Outer Continental Shelf Lands Act; the (Parent company ) may revoke this guaranty, effective on the last day of any annual period of authorization or reauthorization by the Secretary of Labor or designee of (subsidiary company ) to act as a self-insurer under the Longshore and Harbor Workers' ) continuing obligation to guarantee all obligations of (subsidiary company ) whenever accruing, for which (subsidiary company ) is liable under the Longshore and Harbor Workers' Compensation Act and/or its extensions, the Outer I, being the duly elected and acting Secretary of (parent company ) do hereby certify that the foregoing was duly adopted by the Board of Directors of (parent company ) at a meeting thereof duly called and held on (date ), at which a quorum was present and acting throughout, and that said guaranty is in full force and effect.__________________________________________SignatureCorporate Seal _________________________________________________________________ certifica
3 tioncompanyregulatoryreporting[Sectionin
tioncompanyregulatoryreporting[SectioninformalmechanismsrepresentativeseffortsprofessionalresponsibleAdministratorshouldcompanyapplicationnotificationcorrespondencetherelatedmaterial DepartmentAvenue,N.W. telephoneWorkers’Compensation (2/12) REQUIREMENTSFORAUTHORIZATIONINSURED LONGSHOREHARBORWORKERS’ AND/OR Base InsuranceSUBMITTED Insurance.eachobligationsCertifiedauditedstatementseers,lossyear,excessandclassificationentstatementindividualsclaims.selfthe(EIN)company.Thisapplication. certificationcompanyregulatoryreporting[SectioninformalmechanismsrepresentativeseffortsprofessionalresponsibleAdministratorshouldcompanyapplicationnotificationcorrespondencetherelatedmaterial DepartmentAvenue,N.W. telephoneLongshore and Harbor Workersâ Compensation (2/12) certificationcompanyregulatoryreporting[SectioninformalmechanismsrepresentativeseffortsprofessionalresponsibleAdministratorshouldcompanyapplicationnotificationcorrespondencetherelatedmaterial DepartmentAvenue,N.W. telephoneDivision of Federal Employeesâ, (2/12