Bond Required Of Employer Carrying His Own Risk {8}

South Carolina Workers' Compensation Commission SELF-INSURANCE DIVISION 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5706 Page One of Two BOND NUMBER: KNOW ALL MEN BY THESE PRESENTS that and State of South Carolina in the sum of WHEREAS, , a corporation incorporated under the laws of the State of , as Principal, , a corporation incorporated under the laws of the State of day of , as Surety, are held and firmly bound to the , A.D. . dollars, to be paid to the State of South Carolina binding ourselves, our successors and assigns jointly and severally by this document, signed, sealed and dated this compensation directly without insuring under South Carolina Code 42-5-20 (1985). AND WHEREAS, the Commission on the cancelled upon condition that day of , A.D. did file with the South Carolina Workers' Compensation Commission its application for the privilege of paying , passed an order granting privilege continuously until dollars and shall abide by the , employer, enter into bond in the penalty of requirements of the Act with reference to paying or furnishing compensation, medical or surgical services, etc., and the rules and regulations that are now or may be adopted by the Commission. This bond shall take effect at 12:01 a.m. on the cancelled. NOW, THEREFORE, the condition of this obligation is such that shall abide by and perform all of the requirements of the Act and any amendments, as well as the rules and regulations that are or may be adopted by the South Carolina Workers' Compensation Commission respecting the payment of compensation to its injured employees or the dependents of its killed employees, and the furnishing at its own cost the expenses of medical, surgical and other services, and funeral expenses as provided in the Act, then this obligation shall be void. This Bond may be cancelled at any time by the Surety upon giving sixty (60) days written notice to the South Carolina Workers' Compensation Commission, in which event the liability of the Surety shall, at the expiration of sixty days, cease and determine, except as to such liability of the Principal on account of injury or death to any of its employees, as may have accrued prior to the expiration of sixty days, it being understood that the Surety shall be liable, within the penal sum mentioned above, for the default of the Principal in fully discharging any liability on its part. IN WITNESS, the employer has caused this document to be signed by its President, and its corporate seal attached, attested by its Secretary, and the Surety has likewise caused this document to be signed by its President, and its corporate seal attached, attested by its Secretary. Attest: Witness as to Principal By Employer President Address of Witness Attest: Witness as to Surety By President or Authorized Officer of Surety Company Address of Witness I, official seal. __________________________________________________________ Secretary WCC Form # 8 Rev. 07/96 , Secretary of the employer corporation, certify that the resolution adopted on the day of , A.D. Surety day of , A.D. , and shall remain in effect continuously until , the Board of Directors of the employer aforementioned directed and empowered the execution of this bond. In witness sign and affix my 8 BOND REQUIRED OF EMPLOYER CARRYING HIS OWN RISK American LegalNet, Inc. www.FormsWorkFlow.com South Carolina Workers' Compensation Commission SELF-INSURANCE DIVISION 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5706 Page Two of Two STATE OF SOUTH CAROLINA} PROBATE WHERE EMPLOYER IS CORPORATION County BEFORE ME, personally appeared and swore that he saw sign, seal and deliver the Bond, and he subscribed his name as a witness. , as principal, SWORN and subscribed before me this day of , A.D. . ___________________________________________________________ Notary Public STATE OF SOUTH CAROLINA} PROBATE WHERE EMPLOYER IS INDIVIDUAL OR PARTNERSHIP BEFORE ME, the subscribing Notary Public, personally appeared , as principal, before me this day of , A.D. . and swore that he saw sign, seal and deliver the Bond, and he subscribed ___________________________________________________________ Notary Public STATE OF SOUTH CAROLINA} PROBATE AS TO SURETY County BEFORE ME, the subscribing Notary Public, personally appeared , by and he subscribed his name as a witness. SWORN and subscribed before me this day of , A.D. . and swore that he saw as Attorney in Fact, as Surety, sign, seal and deliver the Bond, ___________________________________________________________ Notary Public WCC Form # 8 Rev. 07/96 8 BOND REQUIRED OF EMPLOYER CARRYING HIS OWN RISK American LegalNet, Inc. www.FormsWorkFlow.com