OFFICE OF COMMISSIONER OF INSURANCE COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER•COMPTROLLER GENERAL Ralph T. Hudgens, Commissioner www.oci.ga.gov 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 ◊ Fax: 770-344-5798 ◊ E-mail: TBrewster@oci.ga.gov BOND NON-TRADITIONAL ENTITIES GID-057-NT JAN11 (same as GID-057-EN) Know all men by these presents; THAT,___________________________________________________________________,a ________________________ 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 ______________________________________ type of license under O.C.G.A. §33-1-1 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 company’s possession in connection with his activities, faithful performance of all his duties and, 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, Enforcement Division. At that time and unless notified to the contrary by the Commissioner of Insurance, Enforcement 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__________________________________________ and its corporate seal affixed thereto with attestation where required. (Agent or Attorney in Fact) Principal ( Company Seal ) LICENSEE Authorized Signature Date Signature Title Date Signature ATTEST Title Date Surety ( Surety Seal ) SURETY Authorized Signature Date Signature Title Date Signature Title Date Title Date ATTEST Power-Of-Attorney Attest if required: This office does not discriminate by race, color, national origin, sex religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at: 2 Martin Luther King Jr. Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056 American LegalNet, Inc. www.FormsWorkFlow.com Single Page