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Form LS-275, Agreement and Undertaking, page 1
Moderate · 56/100Form Complexity Index

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What this form asks for

The AI fills all of it, from your answers or your documents.

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.
Fillable fields80
Pages2
Sections18
Form Complexity IndexModerate, 56/100

The AI checks your answers before you download

20 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

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.

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.

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.

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.

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.

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.

And 14 more checks
  • Confirms the 'Name of Financial Institution' issuing the letter of credit is correctly entered.
  • Verifies the 'Total Value of Securities Deposited' is accurately calculated and entered.
  • Checks the 'Where Deposited' field to ensure the location of securities deposit is specified.
  • Validates the 'Par Value of Securities' to ensure it matches the securities' face value.
  • Ensures the 'Deposit Value of Securities' is correctly entered and represents the current deposit value.
  • Confirms the 'Issued By' information for the securities is accurately provided.
  • Verifies the 'Rate of Interest' on the securities is correctly entered.
  • Checks the 'Due Date' of the securities to ensure it is accurately recorded.
  • Validates the 'CUSIP Number' for accuracy and proper association with the securities.
  • Ensures the 'Sequence #' is entered if applicable.
  • Confirms that the 'EIN' (Employer Identification Number) is correctly entered.
  • Verifies that the 'Authorization and Acknowledgement' section is properly completed with the signature of the authorized representative, title, and date.
  • Ensures that the form is notarized with the presence of a Notary Public, their signature, and seal.
  • Confirms that the 'Print or Reset' option is used correctly after reviewing all information for accuracy.

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How to Fill Out Form LS-275(IC) Online for Free in 2026

What the AI walks you through.

  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.

Common Mistakes in Completing Form LS-275(IC)

The ones the AI is built to catch.

Incomplete or Inaccurate Carrier's Name and Address (Principal Office)
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.
Failing to Check the Appropriate Box(es) under Coverage Under
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.
Ignoring or Misunderstanding the Undertaking and Agreement Conditions
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.
Entering an Incorrect or Incomplete Amount of Indemnity Bond
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.
Failing to Enter the Correct Name of Surety Company
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.
Entering an incorrect Amount of Letter of Credit or Name of Financial Institution
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.
Failing to enter the Total Value of Securities Deposited correctly
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.
Entering incorrect information for Where Deposited, Par Value of Securities, Deposit Value of Securities, Issued By, or Rate of Interest
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.
Failing to enter the correct CUSIP Number
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
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.
Failure to Complete Required Fields
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.
Incomplete or Inaccurate Information
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.

Frequently Asked Questions About Form LS-275(IC)

 

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How does the AI fill out Form LS-275(IC)?
You answer a few questions in plain words, or upload a document you already have. The AI reads what you give it and puts each answer into the right field of Form LS-275(IC), on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.
What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is Form LS-275(IC) to fill out?
Form LS-275(IC) has a Form Complexity Index of 56 out of 100, in the moderate tier: 80 fillable fields across 2 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is the purpose of the Agreement and Undertaking (Insurance Carrier) form?
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.
What information does the Office of Workers' Compensation Programs collect from the insurance carrier?
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.
What happens if an insurance carrier fails to comply with the terms of this Agreement and Undertaking?
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.
What is the estimated public reporting burden for completing this form?
The estimated public reporting burden for completing this form is 15 minutes per response.
What information is required for the Amount of Indemnity Bond, Name of Surety Company, Amount of Letter of Credit, Name of Financial Institution, and Total Value of Securities fields?
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.
What is the purpose of the security interest granted to the Office of Workers' Compensation Programs for the Agreement and Undertaking (Insurance 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.
Which regulations does the insurance carrier agree to comply with in the Agreement and Undertaking (Insurance Carrier)?
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.
What are the consequences if the carrier fails to comply with any applicable statutory or regulatory provision, the terms of this Agreement and Undertaking, or any lawful order or communication from the Office of Workers' Compensation Programs?
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.
What is the format for the acknowledgement if the carrier is an individual in the Agreement and Undertaking (Insurance Carrier)?
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.
What is the format for the acknowledgement if the carrier is a corporation in the Agreement and Undertaking (Insurance Carrier)?
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.
What information is required for the Agreement and Undertaking (Insurance Carrier) form?
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.
What is the format for the acknowledgement if the carrier is a partnership?
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.
Is there a specific order in which the signatures should be obtained for this form?
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).
What happens if the form is not completed correctly?
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.
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