Form SI-01 "Self-insurers' Guarantee Agreement" - Kentucky

What Is Form SI-01?

This is a legal form that was released by the Kentucky Department of Workers' Claims - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2005;
  • The latest edition provided by the Kentucky Department of Workers' Claims;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form SI-01 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Workers' Claims.

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Download Form SI-01 "Self-insurers' Guarantee Agreement" - Kentucky

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FORM SI-01
rev. 11/05
COMMONWEALTH OF KENTUCKY
DEPARTMENT OF WORKERS’ CLAIMS
FRANKFORT, KENTUCKY 40601
SELF-INSURERS’ GUARANTEE AGREEMENT
I. Guarantee: That ________________________ (hereinafter “Guarantor”) a
corporation, organized and existing under and by virtue of the laws of the
________________ do hereby agree to assume and guarantee to pay or
otherwise discharge promptly, all the liabilities and obligations of the following
business entity (entities) (hereinafter “Employer(s)”):
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
which are provided for under the provisions of the Workers’ Compensation Act
of the Commonwealth of Kentucky per KRS Chapter 342 (hereinafter “Act”). In
the event that said Employer(s) fails to pay or cause to be paid their Workers’
Compensation liabilities as they become due under said Act, then the Guarantor
covenants and agrees that it will pay same.
II. Guarantor’s Obligation upon Employer’s Default: If the Employer(s) fails
to pay any of their obligations as a self-insurer under the Act, the Guarantor will,
upon demand and without delay, pay each such unpaid amount as required by
the Act to or on behalf of the employee whose injury or disease resulted in that
obligation or the representative or beneficiary of that employee, if appropriate,
(hereinafter collectively called the “Employee”). Guarantor enters this agreement
with the express understanding as a condition precedent to the execution and
acceptance of this agreement, that it is for the benefit of unknown and unnamed
employees and said employees may maintain direct action on this Agreement to
enforce the Guarantor’s obligations . In addition, the Commissioner of the
Department of Workers’ Claims or his representatives, successors or assigns
(hereinafter “Department of Workers Claims”) may maintain direct action on this
Agreement to enforce the performance of the Guarantor’s obligations
hereunder. In any such actions, the employees and Department of Workers’
Claims may recover costs and reasonable attorneys’ fees incurred.
Notwithstanding the foregoing, Guarantor shall be entitled to contest its liability
in any actions brought against it pursuant to this agreement on the same
grounds on which the Employer(s) could do so.
Page 1 of 3
FORM SI-01
rev. 11/05
COMMONWEALTH OF KENTUCKY
DEPARTMENT OF WORKERS’ CLAIMS
FRANKFORT, KENTUCKY 40601
SELF-INSURERS’ GUARANTEE AGREEMENT
I. Guarantee: That ________________________ (hereinafter “Guarantor”) a
corporation, organized and existing under and by virtue of the laws of the
________________ do hereby agree to assume and guarantee to pay or
otherwise discharge promptly, all the liabilities and obligations of the following
business entity (entities) (hereinafter “Employer(s)”):
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
which are provided for under the provisions of the Workers’ Compensation Act
of the Commonwealth of Kentucky per KRS Chapter 342 (hereinafter “Act”). In
the event that said Employer(s) fails to pay or cause to be paid their Workers’
Compensation liabilities as they become due under said Act, then the Guarantor
covenants and agrees that it will pay same.
II. Guarantor’s Obligation upon Employer’s Default: If the Employer(s) fails
to pay any of their obligations as a self-insurer under the Act, the Guarantor will,
upon demand and without delay, pay each such unpaid amount as required by
the Act to or on behalf of the employee whose injury or disease resulted in that
obligation or the representative or beneficiary of that employee, if appropriate,
(hereinafter collectively called the “Employee”). Guarantor enters this agreement
with the express understanding as a condition precedent to the execution and
acceptance of this agreement, that it is for the benefit of unknown and unnamed
employees and said employees may maintain direct action on this Agreement to
enforce the Guarantor’s obligations . In addition, the Commissioner of the
Department of Workers’ Claims or his representatives, successors or assigns
(hereinafter “Department of Workers Claims”) may maintain direct action on this
Agreement to enforce the performance of the Guarantor’s obligations
hereunder. In any such actions, the employees and Department of Workers’
Claims may recover costs and reasonable attorneys’ fees incurred.
Notwithstanding the foregoing, Guarantor shall be entitled to contest its liability
in any actions brought against it pursuant to this agreement on the same
grounds on which the Employer(s) could do so.
Page 1 of 3
III. Guarantor’s Waiver of Defenses and Subrogation Rights: In no event
shall the Guarantor demand or require as a condition of performing its
obligations hereunder that the Department of Workers’ Claims (a) obtain
judgment or exercise any remedies against an Employer(s), (b) exhaust any
rights with respect to any security that an Employer(s) may have posted with the
Commissioner, or (c) notify the Guarantor of any information concerning
amendment(s) to the Act after the date hereof or concerning Employer(s) that
may be relevant to the obligations guaranteed hereunder. The Guarantor hereby
agrees not to assert any subrogation rights that it may have as a result of any
payments made hereunder against any security that Employer(s) has posted or
may post with the Commissioner unless and until the Commissioner returns or
releases the security. In addition, the Guarantor agrees to make the payments
provided for in this Agreement without regard to whether any obligation of the
Employer(s) has been discharged under federal bankruptcy laws or any similar
laws.
IV. Termination of Guarantee: This agreement may be terminated at any time
by Guarantor giving the Commissioner of the Department of Workers Claims
written notice stating when, not less than sixty (60) days from receipt of notice,
such termination shall be effective. It is expressly understood and agreed by
Guarantor that such cancellation, however, is not to affect liabilities incurred
prior to the date of cancellation, or any liabilities or obligations it has under
Kentucky Revised Statute Chapter 342. Furthermore, Guarantor understands
and agrees that the sale or change in ownership of the Employer(s) it
guarantees under this agreement does not terminate this agreement.
V. Reaffirmation of the Guarantee: In his or her sole discretion, the Executive
Director may, from time to time, require the Guarantor to reaffirm its obligations
under this Agreement by re-executing the form of this Agreement as it may
subsequently be revised by the Department of Workers Claims. The Guarantor
shall
comply with the Commissioner’s demand for such a reaffirmation within
fifteen (15) days of its receipt. Notwithstanding the foregoing, the Guarantor
shall remain liable under the terms of this Agreement in the absence of any such
reaffirmation.
VI. Choice of Venue; Consent to Jurisdiction; Waiver of Personal Service:
All actions, suits or proceedings commenced by any person in connection with
this Agreement shall solely and exclusively be brought in a state or federal court
located in Franklin County, Commonwealth of Kentucky. The Guarantor hereby
consents to the jurisdiction of said court in any action or proceeding commenced
in connection with this agreement and waives any objection to venue in
connection therewith. The Guarantor hereby waives personal service of process
or papers to be served in connection with the foregoing and agrees that service
may be made by service upon its registered agent in the Commonwealth of
Kentucky or upon an official of the Employer(s) that the Guarantor has agreed to
guarantee under this agreement.
Page 2 of 3
In the event any provision of this Agreement is deemed to be in violation of law,
such provision shall not impair the validity of any other provision.
This agreement shall be effective as of _________________, 20____ .
Signed, sealed and delivered this day of ,________________ 20____ .
____________________________
Company
____________________________
Title
____________________________
Signature
Attest:
_______________________________
(CORPORATE SEAL)
* Attach hereto a Resolution of the Board of Directors or a certified copy of the
corporate by-laws authorizing the signature(s) displayed on this document
Page 3 of 3
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