Indemnity Agreement By Parent Corporation For Wholly Owned Or Majority Owned Subsidiary {SI-4}

Reset Form INDEMNITY AGREEMENT BY THE PARENT CORPORATION FOR WHOLLY OWNED OR MAJORITY OWNED SUBSIDIARY State Form 36472 (R8 / 11-12) / Form SI-4 WORKER'S COMPENSATION BOARD OF INDIANA 402 West Washington Street, Room W196 Indianapolis, Indiana 46204-2753 www.in.gov/workcomp INSTRUCTIONS: Use a separate form for each subsidiary to be indemnified. Do not alter or modify. KNOW ALL MEN BE THESE PRESENTS, THAT (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 compensation provisions of the Worker's Compensation and Occupational Diseases Acts of the State of Indiana, and in the event that said (Name of Subsidiary) shall not pay or cause to be direct to its employees the compensation due or that may become due under said Acts, then the undersigned parent corporation covenants and agrees that it will pay to all such employees of the named subsidiary such compensation, including a reasonable attorney fee incurred by said employees in any action brought on 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 are hereby empowered and authorized to maintain direct action on this agreement and that the parent corporation does recognize this agreement 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 SIXTY (60) DAYS written notice of its intent to cancel. Such cancellation 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 result of this Indemnity Agreement shall not terminate except-upon order of the Board. This agreement shall be effective as of the Executed at day of this day of 20 20 . . FOR PARENT CORPORATION: Signature Printed name Title ATTESTED BY: Signature of Corporate Secretary Printed name (Seal) American LegalNet, Inc. www.FormsWorkFlow.com