Yes! You can use AI to fill out Form LS-275, Agreement and Undertaking
Form LS-275, Agreement and Undertaking, is used by insurance carriers to authorize writing insurance for compensation under the Longshore and Harbor Workers' Compensation Act. It is crucial for ensuring that carriers meet their obligations for compensation and medical services.
Form Complexity Index
Moderate
56 / 100
| Fillable fields | 80 |
| Pages | 2 |
| Fields per page | 40 |
| Sections | 18 |
| Conditional rules | — |
| Tables & lists | — |
| Instruction pages | — |
| OMB Control No. | 1240-0005 |
| Instafill Form ID | IF-LS-275IC |
Form LS-275(IC) has a moderate Form Complexity Index of 56/100 — 80 fillable fields across 2 pages. Instafill’s AI completes it accurately in under a minute.
Form specifications
| Form name: | Form LS-275, Agreement and Undertaking |
| Form issued by: | U.S. Department of Labor |
| Number of fields: | 80 |
| Number of pages: | 2 |
| FCI: | Moderate (56/100) |
| Version: | 2010 |
| Field instructions: | Form LS-275(IC) Instructions |
| Language: | English |
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How to Fill Out Form LS-275(IC) Online for Free in 2026
Are you looking to fill out a FORM LS-275(IC) form online quickly and accurately? Instafill.ai offers the #1 AI-powered PDF filling software of 2026, allowing you to complete your FORM LS-275(IC) form in just 37 seconds or less.
Follow these steps to fill out your FORM LS-275(IC) form online using Instafill.ai:
- 1 Visit instafill.ai site and select Form LS-275.
- 2 Enter carrier's name and address.
- 3 Fill in indemnity bond and letter of credit amounts.
- 4 Provide details of deposited securities.
- 5 Sign and date the form electronically.
- 6 Check for accuracy and submit form.
Our AI-powered system ensures each field is filled out correctly, reducing errors and saving you time.
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Frequently Asked Questions About Form LS-275(IC)
Form LS-275(IC) has a Form Complexity Index of 56 out of 100, placing it in the moderate complexity tier. This score is calculated deterministically from the form’s own structure using Instafill’s published Form Complexity Index methodology, so it can be reproduced and independently verified — it is not a subjective estimate.
For Form LS-275(IC) specifically, the score reflects 80 fillable fields across 2 pages, grouped into 18 sections. The number of fields is the largest factor in the base score (weighted 36%), followed by how difficult those fields are to complete based on their type, where free-text and signature fields count for more than simple checkboxes (26%). The number of pages that actually contain fields (15%), the amount of conditional “fill-only-if” logic (16%), and how many sections the form is divided into (7%) account for the rest of the base. On top of that base, the index adds points for tables and repeating lists, bundled instruction pages, and dense page layouts — capturing difficulty the base alone can miss.
In practical terms, a moderate score means the form takes real effort: there are enough fields, pages and rules that errors are easy to make by hand. Instafill removes that effort entirely: our AI reads your information, maps each value to the correct field — including the conditional ones — and completes Form LS-275(IC) accurately in under a minute, with every field available for you to review before you download. See exactly how the Form Complexity Index is calculated.
The Agreement and Undertaking (Insurance Carrier) form is used by insurance carriers to authorize and agree to the conditions for writing insurance under various statutes, including the Longshore and Harbor Workers' Compensation Act. Failure to complete and return this form may result in the suspension or revocation of the carrier's authorization.
The Office of Workers' Compensation Programs collects the carrier's name and address, the coverage under various acts, and the carrier's agreement to the conditions outlined in the form. They also collect information about the indemnity bond, letter of credit, and securities deposited by the carrier.
The Office of Workers' Compensation Programs may bring suit under any indemnity bond, draw upon any letters of credit or seize any negotiable securities, collect the interest and principal, and sell or otherwise liquidate the securities if the carrier defaults on any obligations under the Longshore and Harbor Workers' Compensation Act or its extensions, fails to renew deposited letters of credit or securities, or has state insolvency proceedings initiated against them.
The estimated public reporting burden for completing this form is 15 minutes per response.
These fields require the amount of the indemnity bond, the name of the surety company, the amount of the letter of credit, the name of the financial institution, and the total value of the securities deposited by the carrier.
The security interest granted to the Office of Workers' Compensation Programs secures the carrier's liability for payment of all compensation, medical services and supplies, other expenses, and any other obligations due under the Longshore and Harbor Workers' Compensation Act and its extensions.
The insurance carrier agrees to comply with the regulations governing insurance carriers and their deposit of security promulgated by the Department of Labor, including any modifications the Department makes from time to time.
The Office of Workers' Compensation Programs may suspend or revoke the carrier's certificate of authority to write insurance for the payment of compensation under the Longshore and Harbor Workers' Compensation Act and its extensions.
The acknowledgement for an individual carrier requires their signature, the state and county where they signed the instrument, and the notary public's signature and seal.
The acknowledgement for a corporation carrier requires the signature of an officer, the state and county where they signed the instrument, and the notary public's signature and seal.
The Agreement and Undertaking (Insurance Carrier) form requires the name, address, and state of incorporation or organization of the insurance carrier, the name and title of the person signing on behalf of the carrier, and the signature of an authorized representative of the carrier, along with their state and county where they signed the instrument, and the notary public's signature and seal.
The acknowledgement for a partnership carrier requires the signature of a member of the firm, the state and county where they signed the instrument, and the notary public's signature and seal.
Yes, the signature of an authorized representative of the insurance carrier should be obtained first, followed by the signature of the notary public and the signature of the person signing on behalf of the carrier (if applicable).
If the form is not completed correctly, it may be rejected by the receiving party, causing delays in the processing of the related transaction. It is important to ensure that all required information is provided accurately and completely.
Compliance Form LS-275(IC)
Validation Checks by Instafill.ai
1
Ensures that the Carrier's Name and Address are accurately entered and match the legal records.
The AI ensures that the Carrier's Name and Address fields are filled out with precision, cross-referencing the provided information with legal records for accuracy. It checks for any discrepancies between the form data and official documents to prevent errors. The AI also validates the format of the address to ensure it adheres to postal standards. This step is crucial for maintaining the integrity of the insurance carrier's identification on the agreement.
2
Confirms that the appropriate act(s) under 'Coverage Under' are checked based on the insurance carrier's authorization.
The AI confirms that the correct act(s) listed under the 'Coverage Under' section are checked, aligning with the insurance carrier's authorized services. It reviews the carrier's certifications and permissions to ensure that only the applicable acts are selected. This validation is essential to avoid any legal issues arising from unauthorized coverage claims. The AI's thorough check guarantees compliance with the carrier's scope of coverage.
3
Verifies that the 'Undertaking and Agreement Conditions' are read and understood before signing.
The AI verifies that all 'Undertaking and Agreement Conditions' outlined in the document have been acknowledged prior to the signing process. It may prompt the user to confirm understanding or completion of reading these conditions. This step is vital to ensure that the signatory is fully aware of the obligations and terms before entering into the agreement. The AI's role is to facilitate a clear understanding and prevent future disputes.
4
Checks that the 'Amount of Indemnity Bond' is correctly entered and corresponds to the actual bond provided.
The AI checks the 'Amount of Indemnity Bond' field to ensure that the entered value is accurate and corresponds to the actual bond amount provided by the surety company. It cross-verifies this amount with the bond documentation to prevent any inconsistencies. This validation is important for the financial accuracy of the agreement and to confirm that the indemnity coverage is as stipulated. The AI's precision in this check safeguards against financial discrepancies.
5
Validates the 'Name of Surety Company' to ensure it is the correct issuer of the indemnity bond.
The AI validates the 'Name of Surety Company' by ensuring that it matches the actual issuer of the indemnity bond. It checks against a database of licensed surety companies to confirm authenticity. This validation is crucial to establish the legitimacy of the bond and to verify that the surety company is authorized to issue such bonds. The AI's validation process helps maintain the legal and financial integrity of the agreement.
6
Ensures that the 'Amount of Letter of Credit' is accurately entered and reflects the actual letter of credit provided.
This validation check ensures that the 'Amount of Letter of Credit' field is filled with the correct numerical value that corresponds to the actual amount of the letter of credit that has been provided. It cross-verifies this amount against the official letter of credit documentation to prevent any discrepancies. The check also confirms that the amount is represented in the correct currency and format as required by the form. Any deviation from the expected value triggers a prompt for correction to ensure the integrity of the financial information.
7
Confirms the 'Name of Financial Institution' issuing the letter of credit is correctly entered.
This validation check confirms that the 'Name of Financial Institution' field contains the proper and legal name of the institution that issued the letter of credit. It checks against a database of financial institutions to ensure the name is recognized and accurately spelled. This step is crucial to authenticate the source of the letter of credit and to facilitate any necessary correspondence or verification with the institution. The check also ensures that the field is not left blank and that it does not contain any unauthorized characters or abbreviations.
8
Verifies the 'Total Value of Securities Deposited' is accurately calculated and entered.
This validation check verifies that the 'Total Value of Securities Deposited' field accurately reflects the sum of the values of all securities that have been deposited. It involves calculating the total value based on individual security valuations and ensuring that this total matches the figure entered on the form. The check also ensures that the value is presented in the correct unit of currency and that it aligns with the current market value of the securities, if applicable. Any miscalculation or misentry is flagged for review and correction.
9
Checks the 'Where Deposited' field to ensure the location of securities deposit is specified.
This validation check scrutinizes the 'Where Deposited' field to ensure that it clearly specifies the location where the securities have been deposited. It checks for a complete and accurate address or identification of the depository institution. The check is designed to prevent any ambiguity or errors that could hinder the retrieval or verification of the securities. It also confirms that the specified location is a recognized and authorized depository for such transactions.
10
Validates the 'Par Value of Securities' to ensure it matches the securities' face value.
This validation check validates that the 'Par Value of Securities' field accurately represents the face value of the securities that have been deposited. It ensures that the par value entered is consistent with the standard value assigned to the securities and that it is expressed in the correct currency. The check also involves a comparison with the current market value, if necessary, to identify any significant discrepancies that may need to be addressed. This step is essential to maintain the accuracy of the financial information on the form.
11
Ensures the 'Deposit Value of Securities' is correctly entered and represents the current deposit value.
This validation check ensures that the 'Deposit Value of Securities' field is filled with the correct numerical value that reflects the current market value of the securities being deposited. It cross-references the entered amount with the latest available financial data to confirm its accuracy. The check also involves verifying that the format of the entered value adheres to standard financial notation, including the use of commas and decimal points where appropriate. Any discrepancies detected by the validation process are flagged for review to ensure the integrity of the financial information on the form.
12
Confirms the 'Issued By' information for the securities is accurately provided.
This validation check confirms that the 'Issued By' field contains the correct identification of the entity or authority that issued the securities. It involves cross-verifying the provided information with official records to ensure that the name and details of the issuer are accurately captured. The check also ensures that the field is not left blank and that it does not contain any ambiguous or misleading information that could affect the validity of the securities. Any errors or inconsistencies found during the validation are highlighted for correction.
13
Verifies the 'Rate of Interest' on the securities is correctly entered.
This validation check verifies that the 'Rate of Interest' specified for the securities is entered correctly and corresponds to the agreed-upon or legally established rate. It checks for proper formatting, including the use of percentage signs and decimal points, and ensures that the rate is within reasonable and expected ranges for the type of security in question. The check also ensures that the interest rate field is not left blank and is consistent with current financial standards and practices. Any deviation from these standards triggers a prompt for further verification.
14
Checks the 'Due Date' of the securities to ensure it is accurately recorded.
This validation check scrutinizes the 'Due Date' field to ensure that it accurately reflects the maturity date or the date on which the securities must be redeemed or paid. It confirms that the date is entered in a recognized format, typically MM/DD/YYYY, and that it is a valid and plausible date in the future. The check also ensures that the due date is consistent with the terms of the securities and that it has not already passed. Any errors in date entry or logic are flagged for immediate correction to prevent any misunderstandings or legal complications.
15
Validates the 'CUSIP Number' for accuracy and proper association with the securities.
This validation check validates the 'CUSIP Number' to ensure that it is accurate and properly associated with the specific securities being referenced. The CUSIP Number is a unique identifier for securities in the United States and Canada, and this check involves matching the provided number with the official CUSIP database. It ensures that the number is in the correct format, which is typically a nine-character alphanumeric code, and that it corresponds to the securities described in the form. Any mismatch or formatting error is identified for correction to maintain the reliability of the securities identification.
16
Ensures the 'Sequence #' is entered if applicable.
The software ensures that the 'Sequence #' field is populated when it is applicable, based on the specific requirements of the form. It checks for the presence of a sequence number in cases where it is a mandatory field. If the sequence number is optional, the software verifies whether the provided data is consistent with the form's guidelines. It also validates the format of the sequence number to ensure it adheres to the expected pattern or sequence.
17
Confirms that the 'EIN' (Employer Identification Number) is correctly entered.
The software confirms that the 'EIN' (Employer Identification Number) is correctly entered by validating the number against the standard EIN format. It checks for the correct number of digits and the inclusion of any necessary dashes. The software also ensures that the EIN provided is a valid number by cross-referencing it with a database of issued EINs, if available. Additionally, it prevents common input errors by disallowing letters and special characters that are not part of a standard EIN.
18
Verifies that the 'Authorization and Acknowledgement' section is properly completed with the signature of the authorized representative, title, and date.
The software verifies that the 'Authorization and Acknowledgement' section is properly completed by ensuring that all required fields, such as the signature of the authorized representative, their title, and the date, are filled out. It checks for the presence of a signature, either through digital means or by confirming that a signature field has been marked as completed. The software also validates that the date entered is in the correct format and is a logical calendar date. It may prompt the user to review this section if any fields appear to be incomplete or improperly formatted.
19
Ensures that the form is notarized with the presence of a Notary Public, their signature, and seal.
The software ensures that the form is properly notarized by checking for the presence of a Notary Public's signature and seal. It may use image recognition technology to verify the authenticity of the notary seal and compare the signature against a database of known notaries, if available. The software also checks that the notarization section includes all necessary information, such as the notary's commission number and expiration date. It alerts the user if the notarization appears to be missing or incomplete.
20
Confirms that the 'Print or Reset' option is used correctly after reviewing all information for accuracy.
The software confirms that the 'Print or Reset' option is used correctly by ensuring that all information has been reviewed for accuracy before the form is finalized. It prompts the user to confirm that they have checked all entries and that the information provided is correct to the best of their knowledge. The software may also provide a summary of all data entered for a final review before the printing or resetting process. Additionally, it ensures that the reset function clears all fields appropriately, allowing for a fresh start if needed.
Common Mistakes in Completing Form LS-275(IC)
The Carrier's Name and Address (Principal Office) field is a crucial piece of information required in the Agreement and Undertaking (Insurance Carrier) form. Failing to enter the correct and complete information can lead to miscommunication, delayed processing, or even rejection of the form. To avoid this mistake, ensure that the name is spelled correctly and matches the name on the insurance policy, and the address includes the street address, city, state, and zip code. Double-checking the information against the insurance policy or contacting the carrier directly can help prevent errors.
The Coverage Under section of the Agreement and Undertaking (Insurance Carrier) form requires the selection of the appropriate box(es) to indicate the type of coverage being provided. Neglecting to check the correct box(es) can result in incorrect coverage or even the rejection of the form. To prevent this mistake, carefully review the options provided and select all the boxes that apply to the coverage being offered. If unsure, consult the insurance policy or contact the carrier for clarification.
The Undertaking and Agreement Conditions section of the form outlines the terms and conditions of the agreement between the parties. Overlooking or misunderstanding these conditions can lead to disputes or breaches of the agreement. To avoid this mistake, read the conditions carefully and ensure that they are fully understood before signing the form. If any conditions are unclear or require clarification, consult with legal counsel or the carrier for guidance.
The Amount of Indemnity Bond field requires the entry of the amount of the bond being offered. Entering an incorrect or incomplete amount can result in processing delays or even the rejection of the form. To prevent this mistake, double-check the amount against the insurance policy or the carrier's requirements, and ensure that all necessary digits are included. If the amount is subject to change, consider entering a placeholder value and updating it later as needed.
The Name of Surety Company field requires the entry of the name of the company providing the bond. Entering an incorrect or incomplete name can result in processing delays or even the rejection of the form. To prevent this mistake, ensure that the name is spelled correctly and matches the name on the bond. Double-checking the information against the bond or contacting the surety company directly can help prevent errors.
Misstating the amount of the Letter of Credit or providing an incorrect name of the Financial Institution can lead to complications in the processing of the Agreement and Undertaking. To avoid this mistake, double-check the information provided in the Letter of Credit and ensure it matches the details entered on the form. Additionally, verify the spelling and accuracy of the Financial Institution's name. It is recommended to contact the Financial Institution directly if there is any uncertainty.
Incorrectly entering the Total Value of Securities Deposited can result in discrepancies and potential financial consequences. To prevent this mistake, carefully review the securities deposited and their respective values, and ensure the total value is accurately reflected on the form. It is advisable to calculate the total value twice to confirm its accuracy.
Providing incorrect information for Where Deposited, Par Value of Securities, Deposit Value of Securities, Issued By, or Rate of Interest can lead to processing delays and potential financial implications. To avoid this mistake, double-check all the relevant information against the original documents and ensure it is entered correctly on the form. It is recommended to consult with the relevant parties or financial advisors if there is any uncertainty.
Entering an incorrect CUSIP Number can cause complications during the securities processing. To prevent this mistake, ensure the CUSIP Number is obtained from a reliable source and is entered correctly on the form. It is advisable to double-check the CUSIP Number against the original securities documentation.
Failing to sign and notarize the Authorization and Acknowledgement section can delay the processing of the Agreement and Undertaking. To avoid this mistake, ensure all parties involved sign and have their signatures notarized on the form before submitting it. It is recommended to consult with legal counsel if there are any questions regarding the signing and notarization process.
One of the most common mistakes made when filling out the Agreement and Undertaking (Insurance Carrier) form is leaving required fields blank. This oversight can lead to delays in processing the form or even rejection. To avoid this mistake, carefully review the form instructions and ensure that all required fields are completed with accurate and legible information. If a field is not applicable to your situation, make sure to indicate this clearly by writing 'N/A' or 'Not Applicable'. Double-checking your work before submitting the form can help prevent errors and ensure a smoother processing experience.
Another mistake made when filling out the Agreement and Undertaking (Insurance Carrier) form is providing incomplete or inaccurate information. This can lead to misunderstandings or errors in processing the form. To avoid this mistake, make sure to provide all necessary information in the designated fields, and double-check that the information is accurate and up-to-date. If you are unsure about any information required, contact the insurance carrier or consult the form instructions for clarification. Providing clear and complete information will help ensure that the form is processed correctly and efficiently.
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