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Surety Bond Amount Rider Form. This is a Texas form and can be use in Self Insurance Regulation Workers Compensation.
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Tags: Surety Bond Amount Rider, DWC-215, Texas Workers Compensation, Self Insurance Regulation
TEXAS DEPARTMENT OF INSURANCE
Division of Workers’ Compensation
Self-Insurance Regulation, MS-60
7551 Metro Center Dr., Ste 100, Austin, Texas 78744-1609
(512) 804-4775 FAX (512) 804-4776
SURETY BOND AMOUNT RIDER
Bond No.
WHEREAS, Surety Bond No.
has been submitted to and accepted by
the Texas Department of Insurance, Division of Workers’ Compensation, which Bond named
a
(Principal Company Name)
corporation
(State)
with its principal place of business in the City of
State of
(City)
(State)
as Principal and
(Surety Company Name)
as Surety; and
WHEREAS, the Commissioner of the Division of Workers’ Compensation has called for
an increase/decrease in the penal sum of the bond by the amount of
(Circle One)
Dollars ($
(Written Amount)
(Decimal Amount)
).
NOW THEREFORE, in accordance with the provisions of said Bond, the penal sum
thereof is now a total of
Dollars ($
(Written Amount)
(Decimal Amount)
).
It is understood and agreed that said change shall be effective in accordance with the
terms and limitations of said Bond for all past, present, existing and potential liability of the
Surety for said Principal, as a certified self-insurer, without regard to specific injuries, date or
dates of injuries, happenings or events.
It is further agreed and understood that this Bond shall be attached to and form a part of
Bond No.
, the Principal and the Surety hereby reaffirming all of their
obligations and liabilities under said Bond as modified by this rider.
Signed, sealed, and delivered this
day of
,
.
FOR SURETY
Signature: Attorney In-Fact and/or Authorized Representative
Business Name
Printed Name/Title
Business Address
Telephone Number
City/State/Zip
DWC-215 (Rev. 1/06)
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SURETY BOND AMOUNT RIDER
ATTEST
Bond No.
Rider Date
A x Sea Heree
(((Affffiix Seall Herre)))
Affix Seal He
Corporate Secretary of Surety
Printed Name
FOR PRINCIPAL
Signature: Attorney In-Fact and/or Authorized Representative
Business Name
Printed Name/Title
Business Address
Telephone Number
City/State/Zip
ATTEST
Corporate Secretary of Principal
DWC-215 (Rev. 1/06)
A x Sea Heree
(((Affffiix Seall Herre)))
Affix Seal He
Printed Name
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