Scribd Logo
Upload

Welcome to Scribd!

  • 87 views

    Form-Si-Bond Surety Bond - Sample Form

    Uploaded by

    MikeDouglas
    This document is a sample surety bond form for self-insured employers in Oklahoma. It outlines the terms of the agreement between the self-insured employer or principal, the surety or bonding company, and the Oklahoma Workers' Compensation Commission. The surety bond guarantees payment of workers' compensation benefits to employees if the self-insured employer is unable to pay. The form details provisions regarding termination of the bond, liability, replacement of security, insolvency of the employer, and payment of claims and costs. Signatures of representatives of the principal and surety are required at the bottom to execute the bond.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Form-Si-Bond Surety Bond - Sample Form

    Uploaded by

    MikeDouglas
    87 views5 pages
    This document is a sample surety bond form for self-insured employers in Oklahoma. It outlines the terms of the agreement between the self-insured employer or principal, the surety or bonding company, and the Oklahoma Workers' Compensation Commission. The surety bond guarantees payment of workers' compensation benefits to employees if the self-insured employer is unable to pay. The form details provisions regarding termination of the bond, liability, replacement of security, insolvency of the employer, and payment of claims and costs. Signatures of representatives of the principal and surety are required at the bottom to execute the bond.

    Original Description:

    Surety Bond Sample Form

    Original Title

    (UD) Form-SI-BOND

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is a sample surety bond form for self-insured employers in Oklahoma. It outlines the terms of the agreement between the self-insured employer or principal, the surety or bonding company, and the Oklahoma Workers' Compensation Commission. The surety bond guarantees payment of workers' compensation benefits to employees if the self-insured employer is unable to pay. The form details provisions regarding termination of the bond, liability, replacement of security, insolvency of the employer, and payment of claims and costs. Signatures of representatives of the principal and surety are required at the bottom to execute the bond.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    87 views5 pages

    Form-Si-Bond Surety Bond - Sample Form

    Uploaded by

    MikeDouglas
    This document is a sample surety bond form for self-insured employers in Oklahoma. It outlines the terms of the agreement between the self-insured employer or principal, the surety or bonding company, and the Oklahoma Workers' Compensation Commission. The surety bond guarantees payment of workers' compensation benefits to employees if the self-insured employer is unable to pay. The form details provisions regarding termination of the bond, liability, replacement of security, insolvency of the employer, and payment of claims and costs. Signatures of representatives of the principal and surety are required at the bottom to execute the bond.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 5

    FORM-SI-BOND

    SURETY BOND - SAMPLE FORM


    OKLAHOMA WORKERS’ COMPENSATION COMMISSION
    1915 N. STILES AVENUE
    OKLAHOMA CITY, OK 73105

    SURETY BOND OF SELF-INSURER OF WORKERS’ COMPENSATION

    IN THE MATTER OF THE PERMIT OF )


    ) SURETY BOND NO. ___________________________
    ) EFFECTIVE DATE: _____________________________
    Employer, Self-Insurance )
    Permit No.:____________________ )

    KNOW ALL PERSONS BY THESE PRESENTS:

    THAT ___________________________________________ (name of employer) whose

    address is ________________________________________________________________________

    as Principal, and _________________________________________________ (name of Surety), a

    corporation organized under the laws of _______________________________________________

    and authorized to transact a general surety business in the State of Oklahoma, as Surety, whose

    address is ________________________________________________________________________

    are held and firmly bound to the State of Oklahoma in the penal sum of _____________________

    _______________________ Dollars ($_______________________) for which payment we bind

    ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly

    by these presents.

    Sealed with our seal and dated this ______________ day of _________________________,

    20__________ .

    Form-SI-BOND, Page 1 of 5
    WHEREAS, in accordance with the provisions of Section 38 of Title 85A of the Oklahoma
    Statutes, the Principal elected to self-insure, and made application for, and received from the
    Oklahoma Workers’ Compensation Commission, a Self-Insurance Permit, upon a furnishing of
    proof satisfactory to the Commission of the ability to self-insure and to compensate any or all
    employees of said Principal for injury or disability, and their dependents for death incurred or
    sustained by said employees, pursuant to the terms, provisions and limitations of the Oklahoma
    Administrative Workers’ Compensation Act.

    NOW, THEREFORE, the conditions of this bond or obligations are such that if the Principal
    shall pay and furnish compensation pursuant to the terms, provisions and limitations of said
    Administrative Workers’ Compensation Act to its employees for injury or disability, and to
    dependents of its employees for death incurred or sustained by said employees, then this bond
    or obligation shall be null and void; otherwise to remain in full force and effect.

    FURTHERMORE, it is understood and agreed that:

    (1) The Surety does, by these presents, undertake and agree that the obligation of this bond
    shall cover and extend to all past, present, existing and potential liability of said Principal,
    as a self-insurer, to the extent of the penal sum herein named, without regard to specific
    injuries, date or dates of injuries, happenings or events.

    (2) The aggregate liability of the Surety hereunder on all claims whatsoever shall not exceed
    the penal sum of this bond in any event.

    (3) This bond may be terminated at any time by the Surety upon giving thirty (30) days’ written
    notice by certified mail to the Oklahoma Workers’ Compensation Commission, which
    notice shall be deemed to have been given when received by said Commission. The liability
    of the Surety shall cease at the expiration of the thirty days, save and except as to all past,
    present, existing and potential liability of the principal incurred as to self-insurer prior to
    the expiration of the thirty days. This bond shall also terminate upon the revocation of the
    Self-Insurance Permit, save and except as to all past, present, existing and potential liability
    of the Principal, incurred as a self-insurer prior to such revocation; and the Principal and
    the Surety, herein named, shall be notified in writing, by the Oklahoma Workers’
    Compensation Commission, in the event of such revocation.

    (4) Where the Principal posts with the Oklahoma Workers’ Compensation Commission a
    replacement security deposit in the form of a surety bond, irrevocable letter of credit, cash,
    securities or any combination thereof in the full amount as may be required by the
    Oklahoma Workers’ Compensation Commission to secure all incurred liabilities for the
    payment of compensation of said Principal under the Oklahoma Administrative Workers’
    Compensation Act, the Surety is released from the obligations under this surety bond upon
    the date of acceptance by the Oklahoma Workers’ Compensation Commission or said
    replacement security deposit.

    Form-SI-BOND, Page 2 of 5
    (5) If the said Principal shall suspend payment of workers’ compensation benefits or shall
    become insolvent or a receiver shall be appointed for its business, the undersigned Surety
    will become liable for the workers’ compensation obligations of the Principal on the date
    benefits are suspended and the Surety shall pay the full amount of the bond to the
    Oklahoma Workers’ Compensation Commission within fifteen (15) days after receipt of
    written notification by the Oklahoma Workers’ Compensation Commission to begin
    payment under the terms of this bond.

    (6) If the surety and the Oklahoma Workers’ Compensation Commission agree, the surety shall
    pay benefits when due and such payments will be a credit against the penal sum of the
    bond. Administrative and legal costs incurred by the Surety in discharging its obligations
    shall also be a charge against the penal sum of the bond.

    (7) When the Surety exercises its obligation to pay claims, it shall pay benefits due to the
    Principals, injured workers without a formal award of the Oklahoma Workers’
    Compensation Commission and such payment will be a credit against the penal sum of the
    bond. Administrative and legal costs incurred by the Surety in discharging its obligations
    shall also be a charge against the penal sum of the bond.

    (8) If any part or provision of this bond shall be declared unenforceable or held to be invalid
    by a court of proper jurisdiction, such determination shall not affect the validity or
    enforceability of the other provisions or parts of this bond.

    Created 2-1-14

    Form-SI-BOND, Page 3 of 5
    IN WITNESS WHEREOF, the Principal has caused these presents to be executed by the

    signature of its ______________________________________________, and its corporate seal

    attached thereto, attested by its ___________________________________________, and the

    Surety has likewise caused these presents to be executed by the signature of its _______________

    ___________________________________, and its corporate seal attached hereto, attested by its

    _____________________________________ .

    (SEAL) _____________________________________________
    Attest as to Seal: Principal

    ___________________________________ By _________________________________________
    (Title) (Title)

    (SEAL)
    Attest as to Seal:

    ___________________________________ By _________________________________________
    (Title) (Title)

    Countersigned ____________________________________________________________________
    (Resident Representative of Oklahoma)

    (If executed by other than a corporation)

    IN WITNESS WHEREOF, we have hereunto set our hands and seals on the day and date first
    above written.

    _____________________________________________
    Principal

    Witness: By _________________________________________
    (Title)

    __________________________________ ___________________________________________
    Surety

    __________________________________

    Form-SI-BOND, Page 4 of 5
    (If executed by the Surety under a power-of-attorney.

    THIS bond is executed under a power-of-attorney.*

    I certify (or declare) under penalty of perjury under the laws of the State of Oklahoma that
    the foregoing is true and correct.

    __________________________________ ___________________________________________
    Signature of Attorney-In-Fact

    ___________________________________________
    Printed or Typed Name of Attorney-In-Fact

    Countersigned ____________________________________________________________________
    (Resident Representative of Oklahoma)

    * (A copy of the power-of-attorney, entitling or authorizing the person who executed the
    bond to do so for and in behalf of the Surety, must be filed with the Oklahoma Workers’
    Compensation Commission.)

    Form-SI-BOND, Page 5 of 5

    You might also like