Form Mo 580-2624 - Nursing Home Surety Bond

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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
DIVISION OF REGULATION AND LICENSURE
SECTION FOR LONG­TERM CARE REGULATION
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NURSING HOME SURETY BOND
BOND NUMBER
KNOW ALL MEN BY THESE PRESENTS, that we, ____________________________________________________________
(OPERATOR’S NAME)
the operator of __________________________________________________________________________________________
(FACILITY NAME)
located at
____________________________________________________________________________________________
(ADDRESS)
as Principal, and
______________________________________________________________________________________,
(SURETY)
a corporation organized and existing under the laws of the State of ______________________, and authorized to transact
surety business in the State of Missouri, as Surety, are held and firmly bound unto the State of Missouri, for the use and
benefit of injured persons in the aggregate penalty of
________________________________ Dollars ($______________),
for which payment well and truly to be made we bind ourselves, our heirs, executors, administrators, successors and assigns joint­
ly and severally, firmly by these presents.
WHEREAS, the said Principal will be holding in trust monies of residents, and therefore is required to comply with the applicable
provisions of the Omnibus Nursing Home Act (Sections 198.003 to 198.186, RSMo).
NOW, THEREFORE, THE CONDITION OF THE ABOVE OBLIGATION IS SUCH THAT, if the said Principal shall comply with
Sections 198.090 and 198.096, RSMo, and any amendments thereto, and in particular shall not wrongfully deprive a resident or
former resident or the estate of a former resident, through act(s) of the operator or any affiliate or employee of the operator, of
money held in trust, then this obligation shall be null and void, otherwise to remain in full force and effect.
Provided, that any person having a claim against said Principal for any violations of Sections 198.090 and 198.096, RSMo, may
bring suit on this bond in any court of competent jurisdiction.
Provided further, that if the Surety shall so elect, this bond may be cancelled by giving sixty (60) days written notice to the Missouri
Department of Health and Senior Services, with a copy to the Principal, and this bond shall be deemed cancelled at the expira­
tion of said sixty (60) days; but said Surety shall not be discharged from any liability already incurred under this bond or which
shall accrue hereunder before the expiration of said sixty (60) day period.
This bond shall be continuous until cancelled.
This bond shall be effective as of the date signed.
IN WITNESS WHEREOF, the said Principal and the said Surety have affixed their hands and seals on this ______________ day
of
______
________________________________
, ________.
SURETY
PRINCIPAL (LICENSED OPERATOR OF FACILITY)
NAME
NAME
ADDRESS
ADDRESS
ATTORNEY­IN­FACT
SIGNATURE OF OPERATOR, PARTNER, LLC MANAGER/MEMBER OR CORPORATE OFFICER OF
BUSINESS
BY
BY
TITLE
INSURANCE AGENT NAME (NO SIGNATURE REQUIRED)
ADDRESS
TELEPHONE NUMBER
MO 580­2624 (1­09)
PAGE 1 OF 2
DA­638

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