Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Michigan Continuous Surety Bond (Group Of Self Insurers) Form. This is a Michigan form and can be use in Workers Comp.
Loading PDF...
Tags: Michigan Continuous Surety Bond (Group Of Self Insurers), BWC-402G, Michigan Workers Comp,
MICHIGAN CONTINUOUS SURETY BOND
Bond No.
KNOW ALL MEN BY THESE PRESENTS:
THAT we,
,
List all Self-Insured Employers as Principals
of
,
as principal, and
,
of
,
a corporation duly incorporated under the laws of the state of
and authorized to do
business in Michigan, as surety, in the sum of
dollars ($
), for the payment of which to the Michigan Department of Labor &
Economic Growth, Workers' Compensation Agency, hereinafter called the Department,
well and truly to be made, we bind ourselves, our heirs, executors, administrators (or our
successors and assigns in case of a corporation), jointly and severally, firmly by these presents.
WHEREAS, the principal has been granted the privilege of self-insuring its workers'
compensation liabilities under the Michigan Workers' Disability Compensation Act of 1969, as
amended, effective 12:01 a.m.,
, 20
, by the Department; and
WHEREAS, the principal, by virtue of said self-insurers’ status, has undertaken to pay its
employees all compensation, benefits and payments that are due, or which may become due them,
under the terms of the Michigan Workers' Disability Compensation Act of 1969, as amended, on
account of occupational disease, injury or death, with a personal injury date that occurs while it is
self-insured.
NOW, THEREFORE, the condition of this obligation is such that if the principal, its heirs,
executors, administrators (or its successors and assigns in case of a corporation), shall well and
truly discharge and pay all compensation and all other benefits or payments for which it is liable,
or may become liable under the said Act on account of injury, disease or death with a personal
injury date that occurs during the effective period of this bond, then, this obligation shall be void,
otherwise it shall remain in full force and effect. Notwithstanding the number of claimants or the
length of time this bond is in effect, there shall be only one bond amount and in no event shall the
aggregate liability of the Surety exceed the bond amount shown above.
(Rev. 1/04)
Page 1 of 3
American LegalNet, Inc.
www.FormsWorkflow.com
IT IS FURTHER AGREED AND STIPULATED that this bond may be canceled at any
time by the surety upon giving 60 days notice to the principal herein and the Department, in
which event the liabilities of the surety shall, at the expiration of said 60 days, cease and
terminate, except as to such liabilities of the principal with a personal injury date that occurred
during the effective period of the bond and prior to the expiration of said 60 days.
This bond shall be effective
, 20
, until canceled.
IN WITNESS WHEREOF, the said principal has caused these presents to be executed
by the signature of its
and
attested
by
its
, and said surety has likewise caused these presents to be
executed by the signature of its
and has caused its
corporate name and seal to be attested by the signature of
its
(Seal)
,
.
(Surety)
Attest:
Typed Name :
Title:
By:
Typed Name:
Title:
(Principal)
Witness:
Typed Name:
Title:
By:
Typed Name:
Title:
Date:
(Rev. 1/04)
Page 2 of 3
American LegalNet, Inc.
www.FormsWorkflow.com
AFFIDAVIT AND ACKNOWLEDGMENT OF SURETY
STATE OF
)
)
)
COUNTY OF
I, being a Notary Public in and for the State and County aforesaid, do hereby certify
that
personally appeared before me and made oath that
he/she is
of the
,
that he/she is duly authorized to execute the foregoing bond by virtue of a certain power of
attorney of said company, dated
, a copy of which is attached
hereto; that said power of attorney has not been revoked; that the said company has complied
with all the requirements of law regulating the admission of such companies to transact business
in the state of Michigan; that the said company is solvent and fully able to meet promptly all of
its obligations, and the said
thereupon, in the name of and on
behalf of the said company, acknowledged the foregoing writing as its act and deed.
Dated this
day of
, 20
.
Notary Public
My Commission Expires:
ACKNOWLEDGMENT OF PRINCIPAL
STATE OF MICHIGAN
)
)
)
COUNTY OF
I, being a Notary Public in and for the said County and State, do certify that
, as
of
whose name is signed to the above bond, bearing date on the
20
day of
, personally appeared before me in my capacity aforesaid, and acknowledged the same.
I further certify that my term of office expires on the
20
,
day of
,
.
Given under my hand this
day of
20
.
Notary Public
(Rev. 1/04)
Page 3 of 3
American LegalNet, Inc.
www.FormsWorkflow.com
