Self Insurance Bond
Self Insurance Bond Form. This is a Virginia form and can be use in Workers Compensation.
Tags: Self Insurance Bond, 21-A, Virginia Workers Compensation,
BOND NO. KNOW ALL MEN BY THESE PRESENTS, That we ____________________________________________ ____________________________________________________, a corporation organized and existing under the laws of _________________, as Principal, and _________________________________ a corporation duly incorporated under the laws of the State of _____________________, as Surety, are held and firmly bound unto the State of Virginia in the sum of ______________________________________________________________________________________________ Dollars ($____________________), good and lawful money of the United States, to be paid to the said State of Virginia, to the payment whereof we hereby bind ourselves and each of us, our and each of our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents, sealed with our seals and dated this _____________ day of _____________, ______. WHEREAS, the above bound Principal _____________________________________________________________ has heretofore filed with the Virginia Workers' Compensation Commission its application for the privilege, under Section 65.2-801 of the Code of Virginia, 1991, of paying compensation direct to its employees entitled to the same without insuring its liability; and WHEREAS, the said Commission on the _____day of _____________, ____ , granted/renewed the privilege of self-insurance effective ____________________________, _____ at 12:01 A.M., Standard Time, to remain in full force and effect until voluntarily surrendered or revoked by the Virginia Workers' Compensation Commission, upon the condition that the said _____________________________________________________ employer, entered into bond in the penalty of _____________________________________________________________ Dollars, ($________________), conditioned amongst other things that the said employer shall abide by and perform the requirements of the aforesaid Section of the Code of Virginia with reference to paying or furnishing compensation, medical or surgical services, etc., and the rules and regulations that are now or may hereafter be adopted by the said Commission with respect to the same. NOW, THEREFORE, The condition of this obligation is such that if the above bound Principal _______________ ________________________________________ shall well and truly, from time to time, and at all times hereafter, abide by and perform all the requirements of the aforesaid Section of the Code of Virginia, and of any amendments thereto, as well as the rules and regulations that now are or hereafter may be adopted by the said Virginia Workers' Compensation Commission, respecting the payment of compensation to its injured employees or the dependents of its killed employees, and the furnishing at its own cost and expense of medical, and surgical and other services, the funeral expenses as provided in said Act as to agreements approved or awards made by the Commission at any time on account of injuries or deaths occurring during the period for which the privilege is granted, then this obligation shall be void, otherwise it shall 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 mail to the "Self-Insurance Program" of the Virginia Workers' Compensation Commission, in which event the liability of the Surety shall, at the expiration of the said thirty days, cease and determine, except as to such liability of the Principal on account of injury or death of any of its employees, as may have accrued prior to the expiration of said thirty days, it being 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 employer has caused these presents to be executed by the signature of its President, and its corporate seal affixed hereto, attested by its Secretary, and the 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 hereunto affixed, the same to be attested by the signature of _________________________ its _____________________________________. (Principal) By Attest: Secretary. President. (SEAL) (Surety) Attest: By (Title) (Title) VWC Form No. 21-A (rev. 1/1/92) American LegalNet, Inc. www.USCourtForms.com Acknowledgment of Principal if a Corporation STATE OF VIRGINIA, _______________ of _______________, to-wit: I, _________________________________ a notary public in and for the ________________ aforesaid, in the State of Virginia, do certify that _______________________________, President of _____________________________ _____________________________________________________, whose name is signed to the above bond, bearing date on the _______ day of __________________, ______, personally appeared before me in my ______________________ aforesaid, and acknowledged the same. I further certify that my term of office expires on the ______ day of __________________, ______. Given under my hand this _______ day of _____________________, ______. ____________________________________ Notary Public Affidavit and Acknowledgment of Surety STATE OF VIRGINIA, _______________ of _______________, to-wit: I, ________________________________________ a notary public in and for the __________________________ aforesaid, in the State aforesaid, do certify that ________________________________________ personally appeared before me in my ________________ aforesaid and made oath that he is _______________________ of the ________________________________________________ that he is duly authorized to execute the foregoing bond by virtue of a certain power of attorney of said company, dated ____________________________, and recorded in the Clerk's office of the _______________________ of _____________________, in Deed Book No. ___________, Page ________, 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 Virginia; that the said company holds the license certificate of the Commissioner of Insurance authorizing it to do business in the State of Virginia; that the surplus to policyholders of said company is $__________________________ that the penalty of the foregoing bond is not in excess of ten per centum of said sum; that the said company is not by said bond incurring in the aggregate, on behalf or on account of the principal named in said bond, a liability for an amount larger than one-tenth of its surplus to policyholders; that the said company is solvent and fully able to meet promptly all of its obligations, and the said ______________________________ thereupon, in the name and on behalf of the said company, acknowledged the foregoing writing as its act and deed. My term of office expires __________________, _______. Given under my hand this ______ day of ______________, _______. ______________________________________ Notary Public American LegalNet, Inc. www.USCourtForms.com