Form Si-4b - Self-Insurer'S Surety Bond printable pdf download

STATE OF FLORIDA

DIVISION OF WORKERS' COMPENSATION

BUREAU OF MONITORING AND AUDIT

SELF-INSURER'S SURETY BOND

KNOW ALL PERSONS BY THESE PRESENTS:

That ___________________, a company authorized to transact surety business in the State of Florida, as Surety, is

hereby held and bound to the Division of Workers' Compensation, hereinafter referred to as the Division, and to the

entitled employees of ____________________________, a self-insured employer, as Principal, in the aggregate

sum of_______________________ Dollars ($_________________) for the payment of which the Surety binds

itself, its successors and assigns, jointly and severally with the Principal, by these presents:

WHEREAS, in accordance with the provisions of Section 440.38, Florida Statutes, the Principal has received approval

of the Division to self-insure, and desires to file this Surety Bond to secure its liability as an employer pursuant to

Section 440.38(1)(b), Florida Statutes.

NOW, THEREFORE, it is understood and agreed that:

In the event the Principal, as a self-insured employer under the Workers' Compensation Law, the Surety

binds itself to be primarily liable for and on its own account shall pay and discharge any such obligations to the

extent of its remaining liability under this bond forthwith, after written demand by the Division, served personally or

by certified mail upon the Surety. The Division in its sole discretion may direct in said demand that such sums as

may be deemed necessary to secure and discharge any of the aforesaid obligations of the Principal, be paid by the

Surety to the Division, the Florida Self-Insurers Guaranty Association, Inc. or to a designated claimant or entitled

beneficiary or recipient or that the Surety shall undertake or continue the handling of claims against the Principal and

make any appearances before a Judge of Compensation Claims or other court of competent jurisdiction, as an

interested party and on its own behalf, the right of the division to make such demand and directions therein, is

superior and prior to the right of any interested party, beneficiary or recipient.

The Surety undertakes and agrees that the obligations of this Bond shall cover and extend to all past,

present and future liability of the Principal as a self-insured employer under the Workers' Compensation Law and

pursuant to the rules and regulations issued thereunder, to the extent of its remaining liability under this Bond, said

obligations in the manner provided in paragraph 1 above. All liability of the Surety may terminate, however, in

accordance with paragraph 3 herein.

This Bond may be terminated as of 12:01 am and on a specified date by the Surety by and in a written notice

of termination given by certified mail to the Division and to the Principal. Such termination shall not be effective,

however, unless the specified date thereof occurs at least 90 days after the date of such mailing of certified mail and

not earlier. In the event of dispute as to the date of mailing, the postmark date shall be considered the date of mailing.

The liability of the surety shall nevertheless continue as to any and all obligations of the Principal as a self-insured

employer under the workers' Compensation Law arising out of all liability of the Surety under this Bond, upon the

Divisions' acceptance of any new bond or security from or in behalf of the Principal as a substitute for this Bond.

The Division shall notify the Surety as to the date upon which the substitute new bond or security becomes subject

to the claims of Principal's entitled employees or those claiming through such employees. Such substitute new bond

or security shall assume and take over and be subject to the entire liability of this and any previous Bond except as to

liability already paid or discharged, and the substitute new bond or security posted by the self-insurer shall be liable

for all compensable claims presented against the self-insured employer thereafter, without right of contribution from

any prior surety. In no event shall the Surety refuse to honor a legitimate and accurate claim against its Bond solely

because of misrepresentations made to the Surety by a previous surety and/or by the Principal to induce the

Surety to issue its Bond. The liability of the Surety under this bond shall not terminate upon the Division's

acceptance of any new bond or security from or in behalf of the Principal which is in addition to this Bond. The

Surety under this Bond shall continue obligated to the extent of its remaining liability under this Bond prior to the

Division's resort to any such additional bond. However, the Surety under this Bond shall not be liable until all

securities including those which were deposited as additional security subsequent to the effective date of this bond

shall have been used

Form SI-4b (Rev. 09/96)

Page 1 of 2

Form Si-4b - Self-Insurer'S Surety Bond

Related Articles

Related forms

Related Categories