Self Insurers Representatives Bond {OC-407}

State of New York Workers' Compensation Board SELF-INSURERS' REPRESENTATIVE'S BOND ____________________________________________________ (Name of applicant) of ______________________________________________________________________________________, (Address) as Principal, and ___________________________________________________________________________ (Name of surety) of ______________________________________________________________________________________, (Address) a surety company authorized to transact business in the State of New York, as Surety, AGREE that they are firmly bound unto the People of the State of New York in the penal sum indicated herein and for the payment of which, truly to be made, we hereby bound ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by this bond. WHEREAS, the Principal has made application to the Workers' Compensation Board for a license to solicit the business of representing, or engage in representing self-insurers, as defined in subdivision three of Section 50 of the Workers' Compensation Law of the State of New York, before the Workers' Compensation Board. NOW, THEREFORE, the condition of this obligation is such that the said Principal shall well, truly and faithfully perform all the duties required of it under the provisions of subdivision 3-b or 3-d of Section 50 of the Workers' Compensation Law of the State of New York and shall otherwise comply with the rules and regulations promulgated by the Workers' Compensation Board of the State of New York, pertaining to the issuance of said license, for the term of this bond as indicated herein, and in the event of any failure to so perform said duties then the Surety shall be liable up to the amount of the Penal Sum. PENAL SUM: $5,000.00 TERM: _________________ to ________________________ DATED: ___________________________________ (Principal) ___________________________________ (Surety) This bond shall be signed by both Principal and Surety, sealed with the respective corporate seals, if any, and duly acknowledged by each party before a notary public. The acknowledgments together with the Surety's usual Power of Attorney, properly certified, should be attached to the bond. Approved as to Form by __________________________________________________________ (For Board use only) OC-407 (3-97) Prescribed by Chairman Workers' Compensation Board State of New York American LegalNet, Inc. www.FormsWorkFlow.com