JOHN W. OXENDINE COMMISSIONER OF INSURANCE SAFETY FIRE COMMISSIONER INDUSTRIAL LOAN COMMISSIONER COMPTROLLER GENERAL SEVENTH FLOOR, WEST TOWER FLOYD BUILDING 2 MARTIN LUTHER KING JR. DR. ATLANTA, GA 30334 (404) 656-2056 TDD#(404) 656-4031 Rev No: 11/02 Form No: GID-57 OFFICE OF INSURANCE AND SAFETY FIRE COMMISSIONER ADMINISTRATOR FIDELITY BOND KNOW ALL MEN BY THESE PRESENTS, that ______________________________________________________________________________, a Third Party Administrator as defined in the laws of the State of __________________, as Principal, ________________________________, a corporation duly incorporated under the laws of the State of ____________________________, as Surety, are held and firmly bound unto the State of Georgia in the full and just sum of __________________, dollars, current money of the United States, to be paid to the State of Georgia, to the payment we hereby bind ourselves and each of us, and each of our successors and assigns, jointly and severally, firmly by these presents, sealed with our seals and dated this __________day of _______________, ________. WHEREAS, the above bounden _______________________________________ did on the ___________day of ________________, _________file with the Commissioner of Insurance of Georgia an application for a license as a Third Party Administrator under O.C.G.A. § 33-23-100 et seq. NOW, THEREFORE, the condition of this obligation is such that if the above bounden _______________________________________________shall maintain faithful accounting and application of all money coming into the administrator’s possession in connection with his activities as administrator and faithful performance of all his duties and administrator, then this obligation shall be void, otherwise to remain in full force and virtue in law. This Bond may be cancelled at any time by the Surety upon giving thirty (30) days written notice by certified or registered mail to the Commissioner of Insurance of Georgia, Regulatory Services Division. At that time and unless notified to the contrary by the Commissioner of Insurance, Regulatory Services Division, at the expiration of the said thirty (30) days, the liability of the Surety shall cease except as to such liability of the Principal on account of injury or death to any covered employees, as may have accrued prior to the expiration of the thirty (30) days. It is 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 principal has caused these presents to be executed by the signature of the Chairman of its Board of Trustees or appropriate company officer and the said Surety has caused these presents to be executed by the signature of its________________________________ (Agent or Attorney in Fact) and its corporate seal affixed thereto with attestation where required. American LegalNet, Inc. www.FormsWorkflow.com This __________________day of _______________________, _____________. PRINCIPAL:_____________________________________________________________ BY:____________________________________________________________________ TITLE:_________________________________________________________________ SURETY:_______________________________________________________________ (Name of the Surety Company) BY:____________________________________________________________________ TITLE:_________________________________________________________________ ATTEST:_______________________________________________________________ (If required by Power-of-Attorney) TITLE:_________________________________________________________________ (SURETY’S SEAL) Attest as to Seal BY:_____________________________ TITLE:__________________________ American LegalNet, Inc. www.FormsWorkflow.com