GROUP SELF-INSURER JOINT AND SEVERAL INDEMNITY AGREEMENT THAT we, the individual members of the ________________________________, have executed this joint and several indemnity agreement pursuant to the Workers’ Disability Compensation Act of 1969. as amended, MCL 418.611(2). WHEREAS, execution of this indemnification agreement by each initial member and subsequent members accepted into the group will be by reference in the application for membership and by signature on this document as an attachment to the application. Each application and indemnity agreement will be signed by an authorized representative of each employer with legal authority to execute the application and indemnity agreement. WHEREAS, each group member, as a self-insurer, by its signature on the application for membership and this indemnification agreement, hereby acknowledges and accepts joint and several liability with all other group members for all liability incurred by each member, arising under the aforesaid act, and all liability incurred by the group members in the operation of this self-insurers group. WHEREAS, each member, pursuant to Michigan Administrative Code, 408.43e(k) 1984, MR 7, effective July 19, 1984, agrees to comply with all provisions of the Workers’ Disability Compensation Act of 1969, as amended, and further each member understands assessment of the members may be ordered pursuant to Michigan Administrative Code 408.43j(3)c 1984, MR 7, effective July 19, 1984. NOW, THEREFORE, this agreement is in full force and effect this________day of ____________20______ and is irrevocable. Initial members and subsequent approved members are bound by this agreement. This agreement shall become effective for each member on the date of admission into the group. BY:_________________________________________ NOTARY SIGNATURE:___________________________ Type Name of Person Signing TITLE:_______________________________________ COUNTY OF:____________________________________ Title of Person Signing MY COMMISSION EXPIRES:______________________ SIGNATURE:_________________________________ DATE:___________________________________________ AFFIX STAMP: WC-402G (8/05) American LegalNet, Inc. www.FormsWorkflow.com