Arizona > Workers Comp
Self Insurance Workers Compensation Guaranty Bond - Arizona
| Self Insurance Workers Compensation Guaranty Bond Form. This is a Arizona form and can be used in Workers Comp . |
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STATE OF ARIZONA THE INDUSTRIAL COMMISSION OF ARIZONA SELF-INSURANCE WORKERS' COMPENSATION GUARANTY BOND Bond No.________ Know All Persons by These Presents: That__________________________________________________________________________, ("Principal") and_____________________________________ of __________________, as Surety, a corporation organized under the laws of _____________________________ and authorized and licensed to transact the business of surety insurance in the State of Arizona, are held and firmly bound unto The Industrial Commission of Arizona, its agents, successors, assigns, and/or designees in trust for the fulfillment by Principal of its obligations under the Arizona Workers' Compensation Act in the penal sum of _________________________________________________________________________dollars ($____________________________), lawful money of the United States, for the payment of which, the Principal binds itself, its heirs, executors, administrators, successors, and assigns, and the Surety binds itself, its heirs, executors, administrators, successors, and assigns, jointly and severally by the presents: WHEREAS, under the authority of the Arizona Workers' Compensation Act ("Act") (Arizona Revised Statutes, Title 23, Chapter 6), the Principal has made application or been granted permission by The Industrial Commission of Arizona to self-insure the Principal's workers' compensation liabilities under the Act. NOW, THEREFORE, the condition of this obligation is such that if the Principal, its heirs, executors, administrators, successors, or assigns shall pay and furnish workers' compensation benefits to its employees and the dependents of its fatally injured employees as required under the Act and applicable rules, and any other liability, assessment, contribution, or obligation imposed upon the Principal under the Act, then this obligation shall be void, otherwise to remain in full force and effect, subject to the following terms and conditions: American LegalNet, Inc. www.USCourtForms.com Bond No._________ Page 2 1. To the extent of the penal sum of this Bond, the Surety undertakes and agrees that the obligation of this Bond shall cover and extend to all past, present, future, existing, and potential liabilities of the Principal required or imposed under the Act for industrial injuries, accidents, or diseases having a date of injury that occurred during the effective period of this Bond. The effective period of this Bond is deemed to be from ____________________, the date of the Principal's initial authority to self-insure to the effective date of the termination of authority to self-insure, as determined by the records of the Commission. The Surety's obligation for past, present, future, existing and potential liabilities includes liability for temporary and permanent compensation benefits, medical and hospital benefits, death benefits, and any other liability, assessment, contribution, or obligation required or imposed under the Act, including liability for reopened or rearranged claims. 2. In the event the Principal fails to meet its obligations as described in this Bond, is found by a court of competent jurisdiction to be insolvent, bankrupt, appoints a receiver, or otherwise in any way is unable to meet its liabilities or obligations under the Act, the Surety will become liable for all liabilities of the Principal as set forth in this Bond. The obligation of the Surety shall not be stayed pending any proceedings for liquidation, bankruptcy, rehabilitation, receivership, or insolvency of the Principal. Nor shall the obligation of the Surety be stayed pending receipt or delivery of other securities or bonds posted to secure liabilities of the Principal. 3. The Surety shall discharge its obligation under this Bond by payment as set forth in A.R.S. § 23-966 to the extent of the amount of the penal sum of this Bond, upon demand, and prior to the Surety's demand for the institution of suit or other action or demand, if any, against the Principal. The following information, provided to the Surety by The Industrial Commission of Arizona, its agents, successors, assigns, and/or designees, and in a format designated by the Industrial Commission of Arizona, constitutes a demand under this paragraph: a. b. Amounts paid under A.R.S. § 23-966 (total amount paid and amount paid per claim); Name, date of birth, and date of injury for each claimant to whom amounts are paid under A.R.S. § 23-966; and c. Amounts reserved to pay obligations under A.R.S. § 23-966. The Surety shall have forty-five (45) days after receipt by certified mail or electronic transmission of any demand by the Industrial Commission of Arizona to pay the amount American LegalNet, Inc. www.USCourtForms.com Bond No._________ Page 3 thereof without interest charge or accrual on the principal amount of the demand. Thereafter, any demand unpaid shall accrue, from the date of demand until paid, an interest charge at an annual rate of 24%. Such accrued interest shall not be charged against or reduce the penal sum of this Bond. Such interest charge shall be borne as a cost of the Surety in addition to the penal sum. Administrative and legal costs of the Surety, including attorney fees incurred by the Surety in discharging its obligation under this Bond shall not be charged against the penal sum of this Bond. The Surety's request for additional information shall not delay the Surety's obligation to pay under this Bond. 4. With the express written consent of The Industrial Commission of Arizona, or upon demand by the Industrial Commission of Arizona, its agents, successors, assigns, and/or designees, the Surety may discharge its obligation under this Bond by paying to the extent of the amount of the penal sum, the full present value of any and all liabilities or obligations of the Principal described in this Bond. The Surety shall have six (6) months after receipt by certified mail of a demand to pay the full present value without interest charge or accrual on the principal amount of the demand. Thereafter, any demand unpaid shall accrue, from the date of demand until paid, an interest charge at an annual rate of 24%. Such accrued interest shall not be charged against or reduce the penal sum of this Bond. Such interest charge shall be borne as a cost of the Surety in addition to the penal sum. Administrative and legal costs of the Surety, including attorney fees incurred by the Surety in discharging its obligatio
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