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

FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

DIVISION OF WORKERS' COMPENSATION

BUREAU OF OPERATIONS SUPPORT

SELF-INSURANCE SECTION

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.

2. 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 at: Self-Insurance Section, P. O.

Box 5497,Tallahassee, Florida 32314-5497 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

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

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

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