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Form LS-275(SI) Agreement and Undertaking (Self-insured Employer)
What Is Form LS-275(SI)?
This is a legal form that was released by the U.S. Department of Labor - Office of Workers' Compensation Programs on April 1, 2010 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form LS-275(SI)?
A: Form LS-275(SI) is an Agreement and Undertaking form for self-insured employers.
Q: Who needs to fill out Form LS-275(SI)?
A: Form LS-275(SI) needs to be filled out by self-insured employers.
Q: What is the purpose of Form LS-275(SI)?
A: The purpose of Form LS-275(SI) is to establish a self-insured employer's agreement to pay workers' compensation benefits.
Q: Do I need to submit Form LS-275(SI) to any specific authority?
A: Yes, Form LS-275(SI) needs to be submitted to the Office of Workers' Compensation Programs (OWCP).
Form Details:
- Released on April 1, 2010;
- The latest available edition released by the U.S. Department of Labor - Office of Workers' Compensation Programs;
- Easy to use and ready to print;
- Yours to fill out and keep for your records;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form LS-275(SI) by clicking the link below or browse more documents and templates provided by the U.S. Department of Labor - Office of Workers' Compensation Programs.
Download Form LS-275(SI) Agreement and Undertaking (Self-insured Employer)
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