Bond No._______________________ Effective Date___________________ DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF-INSURANCE SECTION SURETY BOND KNOW ALL MEN BY THESE PRESENTS, That _____________________________________________________, an employer as defined in the Florida Workers' Compensation Act as Principal and __________________________, a company authorized to transact surety business in the State of Florida, as Surety, are held and firmly bound unto the State of Florida, and the Florida Self-Insurers Guaranty Association, Inc., pursuant to Sections 440.38 and 440.385, Florida Statutes and Rule 4L-5.108, Florida Administrative Code, as amended, in the full and just sum of dollars, current money of the United States, to be paid to said State of Florida or the Florida Self-Insurers Guaranty Association, Inc. in accordance with the aforementioned laws and rules, to the payment whereof we hereby bind ourselves and each of us, our and each of our successors and assigns, jointly and severally, firmly by these presents, sealed with our seals and dated this _______________ day of _________________ A.D., 20 _________. WHEREAS, The above bounden _________________________________________________________did on the day of ____________, A.D. 20____, file with the Florida Division of Workers' Compensation, its application for the privilege of operating as a Self-Insurer under the provisions of Florida's Workers' Compensation Act. AND WHEREAS, The said Division on the________ day of __________, A.D. 20 _____, approved said privilege, subject to cancellation, upon condition that the said employer enter into bond in the penalty of ___________ dollars conditioned amongst other things that the said employer shall abide by and perform the requirements of the aforesaid Workers' Compensation Law with reference to paying or furnishing compensation, medical or surgical services, etc., and the rules and regulations that are now or may be hereafter be adopted by said Division with respect to the same. NOW THEREFORE, The condition of this obligation is such that if bounden______________________________ shall well and truly, from time to time, and at all times hereafter, abide by and perform all the requirements of the aforesaid Workers' Compensation Law, and of any amendments thereto, as well as the rules and regulations that now are or hereafter may be adopted by the said Florida Division of Workers' Compensation, 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, and surgical and other services, and funeral expenses as provided in said Act, then this obligation shall be void, otherwise to remain in full force and virtue in law. This bond may be canceled at any time by the surety upon giving ninety (90) days written notice to the Florida Division of Workers' Compensation, in which event the liability of the Surety shall, at the expiration of said ninety 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 said ninety days, it being understood that the Surety shall be liable, within the penal sum mentioned herein, for the default of the principal in fully discharging any liability on its part accruing during the life of this obligation. IN WITNESS WHEREOF, The said employer has caused these presents to be executed, and the said Surety has likewise caused these presents to be executed. Attest to seal: _______________________________________ Principal Per_______________________________ Title Attest to seal: _______________________________________ Surety _________________________________________ Per____________________________________ Form SI-4 (Rev. 9/96) Title American LegalNet, Inc. www.FormsWorkflow.com