Department of Labor and Industries Self-Insurance PO Box 44891 Olympia WA 98504-4891 MEMORANDUM OF UNDERSTANDING This is a memorandum of understanding between ____________________________________ an d Self-Insured Employer the Department of Labor and Industries regarding the use of an annuity to secure the pension obligation of ___________________________________ , ____________________ ____________. Claimants Name Claim an d Folio Numbers Whereas, ____________________________________ has been certified to self-insure its workers Employers Name compensation liabilities under the Industrial Insurance Act ofthe State of Washington; and, Whereas, __________________________________________ has sustained an industrial injury or Claimants Name incurred an occupational disease which has resu in the creation of a pension obligation whose lted current present value is $ ______________________; and, Whereas, the self-insurer wishes to secure this obligation by purchasing an annuity issued by ___________________________________________; Insurance Company Name THEREFORE: The Self-Insurer and the Department agree as follows: a) The annuity will be purchased by the selfu-insrer with the Department being listed as the beneficiary. A copy of the annuity is to be provided to the Department. b) The Insurance Company must meet the provisions as specified in RCW 51.44.070 in order to have its annuity acceptable to the Department. c) In the event of a default by the annuity provider, the self-insured employer must re-secure the pension obligation with other acceptable means within forty five days of the default. The self- insured employer remains liable for reimbursing the Department for the quarterly reimbursement of benefits. d) The insurance company should make its paymts to the Departmen ent by the 20th of the month following the end of a calendar quarter. The reimbursement should indicate the claimants name, claim and folio numbers and the employernams e. A quarterly statement will be sent to the self-insured employer indicating the amount that would be due from the annuity provider. e) If the amount of monthly benefits change, the self-insured employer is liable for and must make up any deficiency or would receive a rebate of any excess of the quarterly reimbursements on an annual basis. Any adjustments would be determined in an annual review of the pension obligation. American LegalNet, Inc. F207-129-000 memo of understanding 12-92 www.USCourtForms.com>>>> 2 f) In the event of a default by both the self-insurer and the annuity provider, pension benefits would be sought from the main surety provider for the self-insurer. g) Legal proceedings initiated by any party with respect to this annuity shall be subject to the courts and laws of the State of Washington. This agreement is effective _____________/________/_________ . Date: __________/________/_________ . ____________________________ _______________ Self-Insurers Authorized Signature Department of Labor and Industries Date: _________/________/_________ . ____________________________ ________________ Assistant Director of Self-Insurance American LegalNet, Inc.F207-129-000 memo of understanding 12-92 www.USCourtForms.com