KANSAS DEPARTMENT OF LABOR www.dol.ks.gov Page 1 of 3 AMENDATORY RIDER TO SURETY BOND K-WC 131-A (Rev. 6-12) That this rider is to be attached to and form a part of Bond No. ___________________________ issued by _____________________________________________________ , a Surety, on behalf of the following named corporations: 1. _______________________________________________________________________________ 2. _______________________________________________________________________________ 3. _______________________________________________________________________________ 4. _______________________________________________________________________________ 5. _______________________________________________________________________________ 6. _______________________________________________________________________________ 7. _______________________________________________________________________________ 8. _______________________________________________________________________________ 9. _______________________________________________________________________________ 10. _______________________________________________________________________________ That the Surety hereby agrees that the above named corporations are covered under and subject to the Surety Bond Agreement for Surety Bond No. ________________________. That the Surety company agrees that their obligations under Bond No. ________________________ extend to each of the above named corporations, subject to the terms set out in this Amendatory Rider. The penal amount of this Bond, that being $ __________________ , shall be the liability of the Surety under this Bond as to each corporation named above individually, however, liability of the Surety as to all corporations combined shall not exceed the penal amount of $ ____________________. The effective date of this Amendatory Rider to Bond No. ____________________________ shall be _______________________, ______ . In witness whereof, the parties hereto have caused their names to be signed and this instrument to be sealed by the respective parties thereunder duly authorized. Signed, sealed and delivered this __________ day of ______________________________ , 20_____. FOR PRINCIPAL ATTEST: ____________________________________ Corporate Secretary of Surety ____________________________________ Printed name SIGNATURE PRINTED NAME TITLE DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone (785) 296-4000 · wcselfinsurance@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com Kansas Department of Labor K-WC 131-A (Rev. 6-12) Amendatory Rider to Surety Bond FOR PRINCIPAL SIGNATURE PRINTED NAME TITLE Page 2 of 3 FOR PRINCIPAL SIGNATURE PRINTED NAME TITLE FOR PRINCIPAL SIGNATURE PRINTED NAME TITLE FOR PRINCIPAL SIGNATURE PRINTED NAME TITLE FOR PRINCIPAL SIGNATURE PRINTED NAME TITLE DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone (785) 296-4000 · wcselfinsurance@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com Kansas Department of Labor K-WC 131-A (Rev. 6-12) Amendatory Rider to Surety Bond FOR PRINCIPAL SIGNATURE PRINTED NAME TITLE Page 3 of 3 FOR PRINCIPAL SIGNATURE PRINTED NAME TITLE FOR PRINCIPAL SIGNATURE PRINTED NAME TITLE FOR SURETY SIGNATURE PRINTED NAME TITLE DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone (785) 296-4000 · wcselfinsurance@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com