Form S-4 Indemnity Agreement And Power Of Attorney {S-4}

Form: S-4 - INDEMNITY AGREEMENT AND POWER OF ATTORNEY. This form is used in California workers’ compensation group self-insurance arrangements administered by the Department of Industrial Relations, Office of Self-Insurance Plans (OSIP). It is executed by an affiliate member of a workers’ compensation self-insured group and establishes joint and several liability among the group and all affiliate members for workers’ compensation obligations incurred during membership. The agreement authorizes the group and its designated administrator to act on behalf of the affiliate, including accepting service of process, managing claims administration, posting security deposits, and enforcing indemnity obligations. It also grants the group administrator broad power of attorney to collect funds, manage liabilities, and take necessary legal actions. This agreement is a required condition for issuance and continuation of an Affiliate Certificate of Consent to Self-Insure. www.FormsWorkflow.com