Michigan Continuous Surety Bond (Self Insurer)

MICHIGAN CONTINUOUS SURETY BOND Bond No. We, of as principal, and of List all Self-Insured Employers as Principals , , , , and authorized to do busi ess n a corporation duly incorporated under the laws of the state of in Michigan, as surety, establish this surety bond in the sum of $ for payment to the Mic higan Department of Licensing and Regulatory Affairs (Department), Workers' Compensation Agency (Agency). The Agency grants the principal the privilege 12:01 a.m., , 20 of self-insuring its workers' compensation liabilities under the Michigan Workers' Disability Compensation Act (Act), MCL 418.611, effective , by the Department. As a self-insured employer, the principal shall pay its employees all workers' compensation benefits that are due, or which ma become due, under the Act, MCL 418.101et seq, as a result of a y work-related disease, injury or death, with a personal injury date that occurs while it is self-insured. If the principal, its heirs, executors, administrators (or its successors and assigns in case of a corporation), discharges and pays all workers' compensation benefits with a personal injurydate that occurs during the effective period of this bond, then, this bond shall be void. Otherwise this surety bond shall remain in full force and effect. Notwithstanding the number of claimants or the length of time this bond is in effect, there shall be only one surety bond amount and the aggregate liability of the surety shall not exceed the surety bond amount shown above. Page 1 of 3 (Rev. 8/11) American LegalNet, Inc. www.FormsWorkFlow.com This bond may be cancelled at any time by the surety upon giving 60 day s notice to the principal and the Agency. The liability of the surety shall terminate at the expiration of the 60 days except that the surety shall be liable for workers' compensation benefits with a personal injury date that occurs during the effective period of this surety bond, and before the 60 day expiration date. This surety bond shall be effective , 20 , until canceled. Surety Witness: Print Name: Title: Signature: Print Name: Title: (Print name and address of Surety) Principal Witness: Print Name: Title: Signature: Print Name: Title: (Print name and address of Principal) _________________________________________ Date: Page 2 of 3 (Rev. 8/11) American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT AND ACKNOWLEDGMENT OF SURETY STATE OF _______________) COUNTY OF _______________) As a Notary Public, I certify that acting on behalf of the surety, personally appeared before me and that he or she is of the _________ and that he orshe is authorized to execute this surety bond pursuant to a power of attorney of the company that is dated _______ , a copy of which is attached; that the power of attorney has not been revoked; that the company has complied with all the requirements of law regulating the admission of such companies to transact business in the State of Michigan; and that the company is solvent and fully able to meet promptly all of its surety obligations. , Subscribed and sworn to before me this _____ day of ______, 20___ ___________________________ (Notary Public) ________County, Michigan My commission expires __________. ACKNOWLEDGMENT OF PRINCIPAL STATE OF MICHIGAN ) COUNTY OF____________) Subscribed and sworn to before me this _____ day of ______, 20___ ___________________________ (Notary Public) ________County, Michigan My commission expires __________. Page 3 of 3 (Rev. 8/11) American LegalNet, Inc. www.FormsWorkFlow.com