Surety Bond Name Change Rider {DWC-216}

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 NAME CHANGE RIDER WHEREAS, Surety Bond No. Bond No. submitted to and accepted by the as Principal and Commissioner of the Division of Workers' Compensation, which Bond named (Principal Company Name) (Surety Company Name) as Surety; and WHEREAS, the Principal has changed its name from to (Previous Principal Company Name) (Current Principal Company Name) . It is understood and agreed that said name change shall be effective in accordance with the terms and conditions 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 rider 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 Business Address Telephone Number City/State/Zip ATTEST Affffiix Sea Heree (((Affix Seall Herre))) A x Seal He Corporate Secretary of Surety DWC-216 (Rev. 1/06) Printed Name 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com SURETY BOND NAME CHANGE RIDER Bond No. Rider Date 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-216 (Rev. 1/06) 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com