Bond Form For Self-Insured

DEPARTMENT OF LABOR KNOW ALL PERSONS BY THESE PRESENTS, that __ as Principal, and, _ _________________________________ ________________________________________________ a corporate surety company authorized to do business in the State of Vermont, as surety, are holden and stand firmly bound and obliged unto the State of Vermont, Department of Labor in the full and just sum of $_ ________________________, to the true payment whereof we bind ourselves, our heirs, administrators, executors, successors and assigns, jointly and severally, by these presents. WHEREAS, the Principal has requested that the Vermont Department of Labor grant permission to continue/begin (cross out as appropriate) a Self-Insurance Workers' Compensation Program and whereas the Commissioner has granted permission to continue/begin self-insured status provided that the $_ Principal furnish a Self-Insured Workers' Compensation Bond in the sum of ________________________ and whereas in compliance with this condition, the Principal furnished the bond as stated herein. NOW, THEREFORE, the condition of this obligation is such that if the Principal complies with all the requirements of a Self-Insurer of Workers' Compensation then this obligation shall be void otherwise to remain in full force and effect. PROVIDED, HOWEVER, the surety acknowledges that if the Principal fails to comply with the requirements for a Self-Insurer of Worker Compensation then all sums payable hereunder shall be payable upon demand in writing to the surety by the Commissioner, State of Vermont, Department of Labor. PROVIDED ALSO, upon written approval of the Commissioner, the surety herein shall have the right LI/WC-BOND (6/05) American LegalNet, Inc. www.FormsWorkFlow.com to cancel this bond at any time upon giving the Principal herein and the Commissioner, Vermont Department of Labor at least ninety (90) days written notice. However, termination of this bond by surety shall not relieve it of its obligations hereunder to said employees for any work injury which occurs during the period this bond is in effect. SIGNED, SEALED AND DATED this ________ day of ___________________, 20____. EFFECTIVE this _________ day of _______________________, 20_____. BY: ______________________________ BY: ______________________________ BY: ______________________________ LI/WC-BOND (6/05) American LegalNet, Inc. www.FormsWorkFlow.com