Form A-4 Agreement Of Assumption And Guarantee Of Workers Compensation Liabilities {A-4}

Form A-4 - GUARANTY OF WORKERS' COMPENSATION LIABILITIES. This form is used by the California Department of Industrial Relations, Office of Self-Insurance Plans in connection with workers’ compensation self-insurance. This agreement is executed by a guarantor—often a parent, affiliate, or other financially responsible entity—to guarantee the workers’ compensation liabilities of a self-insured employer operating in California. By signing Form A-4, the guarantor agrees to pay or otherwise discharge all covered workers’ compensation obligations incurred by the self-insurer, subject to the terms of the agreement and applicable law. The form details the scope of the guarantee, conditions for termination, jurisdiction and service provisions, and extensive waivers and enforcement rights in favor of the state. This agreement is typically required as a condition of issuing or maintaining a Certificate of Consent to Self-Insure. www.FormsWorkflow.com