KANSAS DEPARTMENT OF LABOR www.dol.ks.gov Page 1 of 4 SELF-INSURANCE AGGREGATE SURETY BOND K-WC 131 (Rev. 8-13) Surety Bond number: _________________________ Know All Persons by These Presents: That ______________________________________________________________________________ ______________________________________________________________, (hereinafter called Principal) and _______________________________________________________________ of ______________________________________________________________________, as Surety, are held and firmly bound into the PEOPLE OF THE STATE OF KANSAS, for the use and benefit of each and all of the employees of the Principal in the aggregate penal sum of __________________________ ________________________ Dollars ($_________________________), for the payment of which, the Principal binds itself, its heirs, executors, administrators, successors, and assigns, and the Surety binds itself, its successors, and assigns, jointly and severally by these presents: WHEREAS, in accordance with the provisions of Kansas Statutes the Principal elected to self-insure, and made application for, or received from the Division of Workers Compensation, State of Kansas, a Certificate to Self-lnsure. NOW, THEREFORE, the condition of this obligation is such, that if the Principal shall pay or cause to be paid direct to its employees the compensation due in accordance with all the provisions of the Kansas Workers Compensation Act and a Certificate to Self-lnsure received from the Division of Workers Compensation, State of Kansas, then this obligation shall be void; otherwise to remain in full force and effect, subject however, to the following provisions, terms and conditions: 1. This Bond can be amended by an amendatory rider if such a rider is approved by the Kansas Division of Workers Compensation. Such a rider shall be in written form attached to this Bond following written approval of the Kansas Division of Workers Compensation. 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 (Rev. 8-13) Self-Insurance Aggregate Surety Bond Page 2 of 4 2. The Surety undertakes and agrees that the obligation of this Bond shall cover and extend in an aggregate manner to all past, present, future, and existing and potential obligations of the Principal under the Kansas Workers Compensation Act from the date the Principal becomes self-insured, which date being _____________________________________________. Such aggregate obligations for past, present, future, and existing and potential obligations shall extend to the payment for temporary and permanent compensation, medical compensation, death benefits, court costs, assessments and any other liability or assessment required or imposed on the Principal by the Kansas Workers Compensation Act. The obligations of the Surety shall be in the manner set out in this Bond subject to the penal amount of this Bond. This Bond shall be an aggregate bond continuous in form and shall remain in full force and effect until the Surety is released as set out in this agreement. When there is release of Surety approved by the Kansas Division of Workers Compensation, that Surety shall be released as follows: (a) Where the Principal enters into an agreement with a new Surety company, the new Surety shall assume all obligations of the previous Surety and the previous Surety shall be completely released from its obligations under this Bond. The new Surety shall then be liable for all obligations of the Principal as set out in paragraph two of this Bond and all other sections of this Bond; (b) Where the Principal does not obtain a new Surety and the Surety is released by the Division of Workers Compensation. The Surety shall be liable for all past, present and future obligations of the Principal that relate to accidental injury, repetitive trauma or occupational diseases and all liabilities under the Workers Compensation Act which occurred prior to the date of release of such Surety. Such obligations will extend to past, present and future payments of temporary and permanent compensation, medical compensation, death benefits, court costs, assessments and any other liability or assessment imposed on a Principal by the Kansas Workers Compensation Act in regard to accidental injury, repetitive trauma or occupational diseases and all liabilities under the Workers Compensation Act that occur prior to the date of the Surety's release. The date of release of Surety shall be the date when the Surety is advised in writing by the Division of Workers Compensation that they are so released. When a Surety wishes to be released from this agreement, they shall make application for release to the Division of Workers Compensation with a copy of that application to the Principal. However, in no case shall the Division of Workers Compensation require that this agreement be in effect more than 60 days following receipt of the request for a release from the Surety. Such a release of the Surety shall, however, be conditional on the terms set out in paragraph four of this Bond. In the event the Principal shall suspend payment of workers compensation benefits, become insolvent, appoint a receiver, or otherwise in any way is financially unable to meet its obligations under the Kansas Workers Compensation Act, the Surety will become liable for all obligations of the Principal as set out in paragraph two of this agreement and other sections of this Bond. This obligation shall become effective on the date the Principal suspends payment of workers compensation benefits, becomes insolvent, appoints a receiver, or is otherwise financially unable to pay his obligations under the Kansas Workers Compensation Act. The obligations of Surety shall not be stayed pending any proceedings for liquidation of said Principal. 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 3. 4. 5. 6. Kansas Department of Labor K-WC 131 (Rev. 8-13) Self-Insurance Aggregate Surety Bond Page 3 of 4 7. The Surety, subject to approval by the Division of Workers Compensation, shall discharge their obligations under this Surety Bond by adjusting its own claims or contracting with an adjusting company, risk management compan