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 orga nized and existing under the laws of _________________, as Principal, and _________________________________ a corporation duly incorp orated under the laws of the State of _____________________, as Surety, are held and firmly bound unto the State of Virginia in the sum of ______________________________________________________________________________________________ Dollars ($____________________), good and lawful money of the United S tates, to be paid to the said State of Virginia, to the payment whereof we hereby bind ourselves and each of us, our and each of our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents, sealed with our seals and dated this _____________ day of _____________, ______. WHEREAS, the above bound Principal _____________________________________________________________ has heretofore filed with the Virginia Workers Compensation Commission its application for the privilege, under Section 65.2-801 of the Code of Virginia, 1991, of paying compensation direct to its empl oyees entitled to the same without insuring its liability; and WHEREAS, the said Commission on the _____day of _____________, ____ , granted/renewed the privilege of self-insurance effective ____________________________, _____ at 12:01 A.M., S tandard Time, to remain in full force and effect until voluntarily surrendered or revoked by the Virginia Work ers Compensation Commission, upon the condition that the said ________________________________________________ _____ employer, entered into bond in the penalty of _____________________________________________________________ Dollars, ($________________), conditioned amongst other things that the said employer shall abide by a nd 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 b y the said Commission with respect to the same. NOW, THEREFORE, The condition of this obligation is such that if the abo ve 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 adopt ed by the said Virginia Workers Compensation Commission, respecting the payment of compensation to its injured employees or the d ependents of its killed employees, and the furnishing at its own cost and expense of medical, and surgical and other serv ices, the funeral expenses as provided in said Act as to agreements approved or awards made by the Com mission 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, o therwise 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 deter mine, 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 expirat ion of said thirty days, it being understood that the Surety shall be liable, within the penal sum m entioned 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 ex ecuted by the signature of its President, and its corporate seal affixed hereto, attested by its Secret ary, 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) Attest: By Secretary. President. (SEAL) (Surety) Attest: By (Title) (Title) VWC Form No. 21-A (rev. 1/1/92) >>>> 2State of Virginia, do certify that _______________________________, Pres ident of _____________________________ _____________________________________________________, whose name is sig ned to the above bond, bearing date on the _______ day of __________________, ______, personally appeared be fore 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 authori zed to execute the foregoing bond by virtue of a certain power of attorney of said company, dated ___________ _________________, and recorded in the Clerks office of the _______________________ of _____________________, in Deed Book No. ___________, Page ________, that said power of attorney has not been revoked; that the sai d company has complied with all the requirements of law regulating the admission of such companies to transact business in the State of V irginia; that the said company holds the license certificate of the Commissioner of Insura nce 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 a