Indiana > Workers Compensation > Self-Insurance
Indemnity Agreement By Parent Corporation For Wholly Owned Or Majority Owned Subsidiary SI-4 - Indiana
| Indemnity Agreement By Parent Corporation For Wholly Owned Or Majority Owned Subsidiary Form. This is a Indiana form and can be used in Self-Insurance Workers Compensation . |
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : WORKER'S COMPENSATION BOARD OF INDIANA 402 WEST WASHINGTON STREET, ROOM Plaintiff(s) W196 INDIANAPOLIS, IN 46204-2753 -againstwww.in.gov/workcomp Index No. Calendar No. : : : JUDICIAL SUBPOENA (Revised 2003) FORM SI-4 Defendant(s) : ...................................................... : INDEMNITY AGREEMENT BY THE PARENT CORPORATION FOR WHOLLY OWNED OR MAJORITY OWNED SUBSIDIARY (Use a separate form for each subsidiary to be indemnified. Do not alter or modify.) THE PEOPLE OF THE STATE OF NEW YORK KNOW ALL MEN BY THESE PRESENTS, THAT __________________________________ TO (Name of Parent Company) corporation, organized and existing under and by virtue of the laws of the State of __________________________________________________________ do hereby guarantee payment of the compensation, provided for under the GREETINGS: compensation provisions of the Worker's Compensation and Occupational Diseases Acts of the State of Indiana, and in the event that said ___________________________________shallexcuses being laid aside,to be direct you attend before WE COMMAND YOU, that all business and not pay or cause you and each of , the Honorable at the Court to its employees the compensation due or that may become due under said Acts, located at County of then the undersigned parent corporation covenants and agrees that it will pay into all such employees of the named subsidiary such o'clock in the room , on the day of , 20 , at compensation, noon, and at any recessed including a orreasonable attorney and give evidence by asaid employees in any part of thebrought on adjourned date, to testify fee incurred as witness in this action on the action this agreement, with the express agreement and understanding as a condition precedent to the execution and acceptance of this agreement, that it is, for the benefit of all unknown and unnamed employees of said named subsidiary, and that said employees with this subpoena is punishable asauthorized to maintainmake you liable to Your failure to comply are hereby empowered and a contempt of court and will directon whose behalf this subpoena was issued for a maximum penalty of $50 anddoes the party action on this agreement and that the parent corporation all damages sustained as a recognize this agreement result of your failure to comply. as a direct financial guarantee to said employees or the dependents of a deceased employee; that the parent corporation shall have a right to cancel and terminate this agreement at any time upon giving the named subsidiary and the Worker's Compensation Board of , Indiana at least the Witness, Honorable one of the Justices of SIXTY (60) DAYS County, written notice of its intent to cancel. Such cancellation Court in day of , 20 shall not affect its liability as to any compensation for injuries occurring prior to TEN (10) DAYS after the date of cancellation specified in such notice. PROVIDED HOWEVER, that cancellation of this indemnity agreement shall be allowed only upon the presentation of proof of the financial ability of the subsidiary to pay compensation direct and upon the approval of the Worker's Compensation Board of Indiana. The liability of the parent corporation as a Attorney(s) for result of this Indemnity Agreement shall not terminate except-upon order of the Board. This agreement shall be effective as of the_____day of________20___. (Attorney must sign above and type name below) (Name of Subsidiary) Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) : Index No. Calendar No. JUDICIAL SUBPOENA Executed at______________ this________day of_______________ 20________. -against: FOR PARENT CORPORATION: _______________________ Signature _______________________ Printed Name ATTEST: : : ...................................................... ________________________________ Defendant(s) Signature of Corporate Secretary : ________________________________ Printed Name THE PEOPLE OF THE STATE OF NEW YORK _______________________ TO Title GREETINGS: (SEAL) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com
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