Form S-5 Agreement Of Assumption And Guarantee Of Workers Compensation {S-5}

Form: S-5 - AGREEMENT OF ASSUMPTION AND GUARANTEE OF WORKERS’ COMPENSATION LIABILITIES FOR GROUP AND AFFILIATE MEMBERS. This form is used in California group self-insurance programs administered by the Department of Industrial Relations, Office of Self-Insurance Plans (OSIP). The form is executed by a workers’ compensation group self-insurer to assume and guarantee payment of workers’ compensation liabilities incurred by its affiliate member employers. By signing this agreement, the group accepts responsibility for ensuring that all covered workers’ compensation obligations arising during periods of authorized self-insurance are paid, even if an individual affiliate member fails to do so. The agreement applies to current and future affiliate members, remains in effect until all outstanding liabilities are resolved, and is binding on successors and assigns. This form is a required condition for issuance and continuation of affiliate Certificates of Consent to Self-Insure. www.FormsWorkflow.com