Form Si-2 - Surety Bond (Worker'S Compensation Board Of Indiana)
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3WORKER’S COMPENSATION BOARD OF INDIANA
FORM SI-2
402 WEST WASHINGTON STREET, ROOM W196
(Revised 2003)
INDIANAPOLIS, IN 46204-2753
SURETY BOND
Bond Number ______________________
KNOW ALL MEN BE THESE PRESENTS THAT WE
______________________________________________________________________, a/an
________________________ Corporation with principal place of business in the
City of ____________________, State of __________________, as Principal, and
_____________________________________________, a/an _________________________
corporation, authorized to do business in Indiana, as Surety, and held firmly
bound unto the State of Indiana for the use and benefit of all employees of
the Principal and person who may be entitled to medical treatment or compensation
under the Worker's Compensation and Occupational Diseases Acts ("the Acts") of
the State of Indiana, in the sum of _________________________________________
dollars (
), lawful money of the United States, for the payment of
which sum we bind ourselves, our successors and assigns, jointly and
severally firmly by these presents.
WHEREAS, the principal has been granted the privilege of self-insuring its
workers' compensation liabilities under the Acts, as amended,
WHEREAS, the principal, by virtue of said self-insurer status, has undertaken
to pay employees all compensation, benefits and payments that are due, or
which may become due, then under the terms of the Acts, as amended, on
account of occupational disease, injury or death, with a personal injury date
that occurs while it is self-insured.
NOW, THEREFORE, the condition of this obligation is such that if the
principal, its heirs, executors, administrators (or its successors and
assigns in case of a corporation), shall well and truly discharge and pay all
compensation and all other benefits or payments for which it is liable, or
may become liable under the said Act on account of injury, disease or death
with a personal injury date that occurs during the effective period of this
bond, then this obligation shall be void, otherwise it shall remain in full
force and effect.
THE CONDITION OF THE FOREGOING OBLIGATION IS SUCH that the following
conditions shall also apply to this surety bond:
1) The Surety does, by these presents, undertake and agree that the
obligation of this bond shall cover and extend to all past, present, existing
and potential liability of said Principal, as a self-insurer, to the extent
of the penal sum herein named, without regard to specific injuries, date(s)
of injuries, happenings or events.
2) This bond shall be continuous in form and shall remain in full force and
effect unless terminated in the manner hereinafter provided.
S-2798 (8/03)
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