Form Si-4b - Self-Insurer'S Surety Bond Page 2
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1
24.
This Bond and the obligations hereunder and herein, shall otherwise remain and continue in full force and effect
so long as the liability of the Principal as a self-insured employer under the Workers' Compensation Law exists.
5.
The effective date of this bond is __________________________.
6.
The identification number for this bond is_______________________________
IN WITNESS WHEREOF the Principal has signed or caused this Bond to be duly signed, and its seal hereto affixed
at_____________________________ this _____________________day of _________________,20____.
__________________________________________
PRINCIPAL
_________________________________________
By
_________________________________________
Title
_________________________________________
Business Address
IN WITNESS WHEREOF the Surety has signed or caused this Bond to be duly signed, and its seal hereto affixed
at______________________ this ___________________day of ________________________, 20_______.
________________________________________
SURETY
_________________________________________
By
________________________________________
Title
________________________________________
Business Address
Form SI-4b (Rev. 09/96)
Page 2 of 2
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