Wcc Form 8 - Bond Required Of Employer Carrying His Own Risk

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South Carolina Workers’ Compensation Commission

Page One of Two

SELF-INSURANCE DIVISION

1333 Main Street, Suite 500

P.O. BOX 1715

Columbia, SC 29202-1715

(803) 737-5704

BOND NUMBER:

KNOW ALL MEN BY THESE PRESENTS that __________________________________, a corporation incorporated under the laws of the State

of __________________, as Principal, and ____________________________, a corporation incorporated under the laws of the State of

__________________, as Surety, are held and firmly bound to the State of South Carolina in the sum of ____________________ dollars, to be

paid to the State of South Carolina binding ourselves, our successors and assigns jointly and severally by this document, signed, sealed and

dated this _________ day of _____________, A.D. _________.

WHEREAS, _________________________________ did file with the South Carolina Workers’ Compensation Commission its application for

the privilege of paying compensation directly without insuring under South Carolina Code 42-5-20 (1985).

AND WHEREAS, the Commission on the _________ day of _____________, A.D. _________, passed an order granting privilege continuously

until cancelled upon condition that _______________________________________, employer, enter into bond in the penalty of

_________________ dollars and shall abide by the requirements of the Act with reference to paying or furnishing compensation, medical or

surgical services, etc., and the rules and regulations that are now or may be adopted by the Commission.

This bond shall take effect at 12:01 a.m. on the __________ day of _____________, A.D. _________, and shall remain in effect continuously

until cancelled.

NOW, THEREFORE, the condition of this obligation is such that ______________________________ shall abide by and perform all of the

requirements of the Act and any amendments, as well as the rules and regulations that are or may be adopted by the South Carolina Workers’

Compensation Commission respecting the payment of compensation to its injured employees or the dependents of its killed employees, and the

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

shall be void.

This Bond may be cancelled at any time by the Surety upon giving sixty (60) days written notice to the South Carolina Workers’ Compensation

Commission, in which event the liability of the Surety shall, at the expiration of sixty 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 sixty days, it being understood

that the Surety shall be liable, within the penal sum mentioned above, for the default of the Principal in fully discharging any liability on its part.

IN WITNESS, the employer has caused this document to be signed by its President, and its corporate seal attached, attested by its Secretary,

and the Surety has likewise caused this document to be signed by its President, and its corporate seal attached, attested by its Secretary.

Attest:

Witness as to Principal

Employer

President

Address of Witness

Attest:

Witness as to Surety

Surety

President or Authorized Officer of Surety Company

Address of Witness