Wage Payment Surety Bond Form - West Virginia Division Of Labor
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4WEST VIRGINIA DIVISION OF LABOR
CAPITOL COMPLEX, BUILDING 6, ROOM 749-B
CHARLESTON, WEST VIRGINIA 25305
WAGE PAYMENT SURETY BOND FOR
LIMITED LIABILITY COMPANY, LIMITED LIABILITY PARTNERSHIP,
CORPORATION OR OTHER BUSINESS ENTITY
Authorized by W. Va. Code §21-5-14(c)
Bond Number
KNOW ALL MEN BY THESE PRESENTS THAT (1)__________________________________________________
Name of Principal
☐ limited liability company ☐ limited liability partnership ☐ corporation ☐ other business entity
(2)__________________________________ the Principal, and (3)___________________________________, as Surety,
Explain
Name of Surety
licensed to do business in the State of West Virginia by the Office of the Insurance Commissioner, bind ourselves, our heirs,
executors, administrators, successors, and assigns, jointly and severally, to the West Virginia Division of Labor in the full
amount of (4)____________________ dollars ($___________________) to secure and guarantee the payment of wages
and fringe benefits of the Principal’s employees
.
The Principal is engaged in (5) ☐ construction work or ☐ the severance, production or transportation of minerals,
and is required by the Wage Payment and Collection Act, W. Va. Code §21-5-14, to furnish this wage bond. As long as the
Principal honors its statutory responsibility to pay employee wages and fringe benefits when they are due, no claim will be
made against this bond. If the Principal defaults or otherwise fails to pay employee wages and fringe benefits as required by
the Wage Payment and Collection Act, the Surety guarantees that it will honor the Division of Labor’s demand for payment
under this bond upon the Principal’s default or failure to pay employee wages and fringe benefits.
The continuing nature of this bond is such that it is required to remain in effect for a period of 5 years from the
bond’s effective date unless the Surety gives written notice by certified mail, return receipt requested, to the Commissioner of
the Division of Labor and the Principal that the Surety intends to cancel the bond 60 days after the post-marked date of the
written notice.
Pertinent sections of the Wage Payment and Collection Act and the legislative rule promulgated thereunder,
“Employer Wage Bonds,” 42 CSR 33, are expressly incorporated as if they were fully set forth herein and are made a part of
this bond. The effective date of the bond is the (6)_______day of ____________________, __________.
IN WITNESS WHEREOF, the said Principal has hereunder set its hand and affixed its seal, and the said surety has
caused its corporate name to be signed hereto and its corporate seal to be hereunder affixed by its duly authorized officer or
agent and executed this the (7) ____________ of ________________________, ________.
8)
_________________________________________
9)
________________________________________
Principal
Surety Corporation
_________________________________________
________________________________________
Complete Address of Principal
Address of Surety Corporation
Page 1 of 4
WVAGO Approved Form
Last Revised 9/25/14
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