Page One of Two South Carolina Workers’ Compensation Commission SELF-INSURANCE DIVISION 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5706 BOND NUMBER: , a corporation incorporated under the laws of the State of KNOW ALL MEN BY THESE PRESENTS that , a corporation incorporated under the laws of the State of and State of South Carolina in the sum of , as Principal, , as Surety, are held and firmly bound to the 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 day of , A.D. . did file with the South Carolina Workers’ Compensation Commission its application for the privilege of paying WHEREAS, 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. , passed an order granting privilege continuously until , employer, enter into bond in the penalty of dollars and shall abide by the 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 day of , A.D. , and shall remain in effect continuously until 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 Surety By President or Authorized Officer of Surety Company Address of Witness I, , Secretary of the employer corporation, certify that the resolution adopted on the day of , A.D. , the Board of Directors of the employer aforementioned directed and empowered the execution of this bond. In witness sign and affix my official seal. __________________________________________________________ Secretary WCC Form # 8 Rev. 07/96 8 BOND REQUIRED OF EMPLOYER CARRYING HIS OWN RISK American LegalNet, Inc. www.FormsWorkFlow.com Page Two of Two South Carolina Workers’ Compensation Commission SELF-INSURANCE DIVISION 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5706 STATE OF SOUTH CAROLINA} County PROBATE WHERE EMPLOYER IS CORPORATION and swore that he saw BEFORE ME, personally appeared , as principal, sign, seal and deliver the Bond, and he subscribed his name as a witness. SWORN and subscribed before me this day of , A.D. . ___________________________________________________________ Notary Public STATE OF SOUTH CAROLINA} PROBATE WHERE EMPLOYER IS INDIVIDUAL OR PARTNERSHIP and swore that he saw BEFORE ME, the subscribing Notary Public, personally appeared , as principal, before me this day of , A.D. sign, seal and deliver the Bond, and he subscribed . ___________________________________________________________ Notary Public STATE OF SOUTH CAROLINA} PROBATE AS TO SURETY County and swore that he saw BEFORE ME, the subscribing Notary Public, personally appeared , by as Attorney in Fact, as Surety, sign, seal and deliver the Bond, and he subscribed his name as a witness. SWORN and subscribed before me this day of , A.D. . ___________________________________________________________ Notary Public WCC Form # 8 Rev. 07/96 8 BOND REQUIRED OF EMPLOYER CARRYING HIS OWN RISK American LegalNet, Inc. www.FormsWorkFlow.com