Les Form Si-4 - Surety Bond printable pdf download

Bond No.

________________________________

Effective Date

________________________________

FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

DIVISION OF WORKERS' COMPENSATION

BUREAU OF OPERATIONS SUPPORT

SELF-INSURANCE SECTION

SURETY BOND

KNOW ALL MEN BY THESE PRESENTS, That __________________________________________________________, an

employer as defined in the Florida Workers' Compensation Act as Principal and __________________________, a company

authorized to transact surety business in the State of Florida, as Surety, are held and firmly bound unto the State of Florida,

Department of Labor and Employment Security and the Florida Self-Insurers Guaranty Association, Inc., pursuant to Sections

440.38 and 440.385, Florida Statutes and Rule 38F-5.108, Florida Administrative Code, as amended, in the full and just sum

of _______________ dollars, current money of the United States, to be paid to said State of Florida or the Florida Self-

Insurers Guaranty Association, Inc. in accordance with the aforementioned laws and rules, to the payment whereof we hereby

bind ourselves and each of us, our and each of our successors and assigns, jointly and severally, firmly by these presents,

sealed with our seals and date this _______________ day of _______________ A.D., 19 __________ .

WHEREAS,

The

above

bounden

_______________________________________________________

did

the

_______________ day of _______________, A.D.

19 __________ , file with the Florida Department of Labor and

Employment Security, Division of Workers' Compensation, its application for the privilege of operating as a Self-Insurer under

the provisions of Florida's Workers' Compensation Act.

AND WHEREAS, The said Division on the _______________ day of _______________, A.D. 19 __________, approved said

privilege, subject to cancellation, upon condition that the said employer enter 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

Workers' Compensation Law with reference to paying or furnishing compensation, medical or surgical services, etc., and the

rules and regulations that are now or may be hereafter be adopted by said Division with respect to the same.

NOW THEREFORE, The condition of this obligation is such that if bounden ________________________________________

shall well and truly, from time to time, and at all times, hereafter, abide by and perform all the requirements of the aforesaid

Workers' Compensation Law, and of any amendments thereto, as well as the rules and regulations that now are or hereafter

may be adopted by the said Florida Department of Labor and Employment Security, Division of Workers' Compensation,

respecting the payment of compensation to its injured empoyees or the dependents of its killed employees, and the furnishing

at its own cost the expenses of medical, and surgical and other services, and funeral expenses as provided in said Act, then

this obligation shall be void, otherwise to remain in full force and virtue in law.

This bond may be canceled at any time by the surety upon giving ninety (90) days written notice to the Florida Department of

Labor and Employment Security, Division of Workers' Compensation, in which event the liability of the Surety shall, at the

expiration of said ninety days, cease and determine, except as to such liability of the Principal on account of injury or death to

any of its employees as may have accrued prior to the expiration of said ninety 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, and the said Surety has likewise

caused these presents to be executed.

Attest to seal:

_____________________________________________

Principal

_____________________________________________

Per __________________________________________

Title

Attest to seal:

_____________________________________________

Surety

_____________________________________________

Per __________________________________________

Title

LES Form SI-4 (Rev. 9/96)

Les Form Si-4 - Surety Bond

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