Self Insurers Pension Bond printable pdf download

Department of Labor and Industries

SELF-INSURER’S

Self-Insurance Section

PO Box 44891

PENSION BOND

Olympia WA 98504-4891

Express Mail:

7273 Linderson Way SW

BOND NO:

Tumwater WA 98501

KNOW ALL PERSONS BY THESE PRESENTS, that_______________________________

_________________________________________, as Principal, having its principal office at

_____________________________________________________________________________,

and_________________________________________________________________________, a

company authorized to transact surety business in the state of Washington, having its principal

office at _____________________________________________, as Surety are held and firmly

bound unto the STATE OF WASHINGTON, DEPARTMENT OF LABOR AND INDUSTRIES,

in the penal sum of _______________________________________________ DOLLARS

($________________), the payment of which the Principal and Surety bind themselves, their

heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these

presents.

The condition of the above obligation is such that the said Principal has elected to reimburse the

said Department, under the provisions of RCW 51.44.070, for the payments to be made from the

Pension Reserve Fund for claim number ____________________________________________,

claimant___________________________________________.

NOW THEREFORE, it is understood and agreed that:

1. If the Principal shall reimburse the Department for all payments by the Department from the

Pension Reserve Fund to the claimant according to the terms and provisions of RCW 51.44.070,

then this obligation shall be null and void; otherwise it remains in full force and effect. The

Surety agrees that it may not assign or transfer its rights, remedies, obligations or causes of action

under this bond without written approval of the Department of Labor and Industries.

2. The pension reserve associated with this obligation shall be reviewed annually. Any change

to the penal sum of this bond will extend to the entire pension obligation and be issued on the

Department’s pension bond rider, which will be attached to this bond.

3. This bond is subject to acceptance by the Self-Insurance Program Manager. The original will

be filed in the Self-Insurance Section of the Department of Labor and Industries.

4. This bond is continuous in form and shall remain in full force and effect unless terminated in

the manner hereinafter provided.

5. This bond may not be terminated by either the Principal or the Surety unless the Principal

shall first provide a cash deposit or substitute bond in accordance with the terms of RCW

51.44.070.

6. The Principal and the Surety are held and firmly bound for the payment of all legal costs,

including reasonable attorney’s fees incurred in any or all actions or proceedings taken to enforce

payment under this bond, or payment of any award or judgment rendered against the Surety, on

account of the execution of this bond.

7. The effective date of this bond is ____________________________.

F207-065-000 (w) self-insurer’s pension bond 10-01 page 1

Self Insurers Pension Bond

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