Self Insurers Pension Bond (Page 2 of 2) in pdf

Self Insurers Pension Bond Page 2

Name of Claimant

Claim Number

Bond Number

8. If the Principal shall cease reimbursing the Department for payments made by the Department

to the beneficiary or beneficiaries, and demand is made upon the Surety, the Surety shall pay any

delinquent reimbursements owed by the Principal. The Surety shall then have the option to:

A. Pay the Department a sum of money equal to the cash value of the remaining pension

reserve as calculated annually by the Department, or,

Continue to pay the quarterly reimbursement owed by the Principal to the Department of

Labor and Industries until such obligation ceases or until the Surety exercises the option

of paying the cash value of the pension reserve as calculated by the Department.

Quarterly reimbursements paid by the Surety shall not be limited to the penal sum of this

bond nor shall they be deducted from the penal sum of this bond.

Principal

Name

Date

Title

Signature

Surety

Name

Date

Title

Signature

Accepted by the State of Washington

Department of Labor and Industries

Date

Self-Insurance Program Manager

F207-065-000 (w) self-insurer’s pension bond 10-01 page 2

Self Insurers Pension Bond Page 2