Form Il446-0152 - Third Party Administrator Bond

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Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767-0001
Third Party Administrator Bond
Co. Code # ________________
Bond # ___________________
KNOW ALL MEN BY THESE PRESENTS, THAT I/we ___________________________________________
of __________________________________________________________________, a Third Party Administrator
as principal and ___________________________________________________________ a company duly
authorized to transact surety business in the State of Illinois, as Surety, are held and firmly bound unto the People of
the State of Illinois and payable to any party injured under the terms and conditions of this bond, in the full and penal
sum of ___________________________ ($
) dollars lawful money of the United States of America,
for the payment of which, well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors
and assigns, jointly and severally, firmly by these presents.
THE CONDITION OF THIS OBLIGATION IS SUCH that the above bonded Principal is now or is about to
become licensed to engage or continue in the business of a Third Party Administrator, as provided by the Illinois
Insurance Code, as amended.
NOW, THEREFORE, if the said Principal shall, while this bond is in force and effect make a full accounting and
due payment to the person or company entitled thereto of funds coming into his possession as an incident to Third
Party Administrator transactions, and shall comply with all the provisions of Section 511.104 of the Illinois Insurance
Code, as amended, then this obligation shall be null and void; otherwise to remain in full force and effect.
PROVIDED, HOWEVER, that this bond shall be continuous in form and may be terminated by the Surety, upon
its giving thirty (30) days notice of its intention of termination, such notice to be filed with the Director, Department of
Insurance, Springfield, Illinois.
IN WITNESS WHEREOF, the said principal has hereunto set his hand and seal, and the said surety has
caused these presents to be signed by its duly authorized officers and its corporate seal to be hereto affixed this
_________ day of _____________________, 20______.
*(Signature of Principal)--Social Security Number
(Bonding Company)
(Signature of Company Officer)
(Signature of Attorney-in-Fact)
*If a Corporation, signature and social security number of all
authorized members.
Important Notice: Under the Illinois Revised Statutes' insurance laws, disclosure of this information is voluntary; however, failure to comply
may result in this form not being processed. This form has been approved by the Forms Management Center.
IL446-0152 Rev. 6/09
Third Party Administrator Bond

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