Surety Bond Amount Rider {DWC-215}

TEXAS DEPARTMENT OF INSURANCE Division of Workers' Compensation Self-Insurance Regulation, MS-60 7551 Metro Center Dr., Ste 100, Austin, Texas 78744-1609 (512) 804-4775 FAX (512) 804-4776 SURETY BOND AMOUNT RIDER WHEREAS, Surety Bond No. Bond No. has been submitted to and accepted by a (City) the Texas Department of Insurance, Division of Workers' Compensation, which Bond named (Principal Company Name) (State) corporation State of with its principal place of business in the City of (State) as Principal and as Surety; and (Surety Company Name) WHEREAS, the Commissioner of the Division of Workers' Compensation has called for an increase/decrease in the penal sum of the bond by the amount of (Circle One) (Written Amount) Dollars ($ (Decimal Amount) ). NOW THEREFORE, in accordance with the provisions of said Bond, the penal sum thereof is now a total of (Written Amount) Dollars ($ (Decimal Amount) ). It is understood and agreed that said change shall be effective in accordance with the terms and limitations of said Bond for all past, present, existing and potential liability of the Surety for said Principal, as a certified self-insurer, without regard to specific injuries, date or dates of injuries, happenings or events. It is further agreed and understood that this Bond shall be attached to and form a part of Bond No. , the Principal and the Surety hereby reaffirming all of their obligations and liabilities under said Bond as modified by this rider. Signed, sealed, and delivered this FOR SURETY day of , . Signature: Attorney In-Fact and/or Authorized Representative Business Name Printed Name/Title Telephone Number DWC-215 (Rev. 1/06) Business Address City/State/Zip 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com SURETY BOND AMOUNT RIDER Bond No. Rider Date ATTEST A x Sea Heree (((Affffiix Seall Herre))) Affix Seal He Corporate Secretary of Surety Printed Name FOR PRINCIPAL Signature: Attorney In-Fact and/or Authorized Representative Business Name Printed Name/Title Business Address Telephone Number City/State/Zip ATTEST A x Sea Heree (((Affffiix Seall Herre))) Affix Seal He Corporate Secretary of Principal Printed Name DWC-215 (Rev. 1/06) 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com