Michigan > Workers Comp
Michigan Continuous Surety Bond (Self Insurer) - Michigan
| Michigan Continuous Surety Bond (Self Insurer) Form. This is a Michigan form and can be used in Workers Comp . |
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MICHIGAN CONTINUOUS SURETY BOND Bond No. We, List all Self-Insured Employers as Principals , , , , and authorized to do of as principal, and of a corporation duly incorporated under the laws of the state of business in Michigan, as surety, establish this surety bond in the sum of $ for payment to the Michigan Department of Energy, Labor & Economic Growth, Workers' Compensation Agency (Agency). The Agency grants the principal the privilege of self-insuring its workers' compensation liabilities under the Michigan Workers' Disability Compensation Act (Act), MCL 418.611, effective 12:01 a.m., , 20 , by the Department. As a self-insured employer, the principal shall pay its employees all workers' compensation benefits that are due, or which may become due, under the Act, MCL 418.101 et seq, as a result of a work-related disease, injury or death, with a personal injury date that occurs while it is selfinsured. If the principal, its heirs, executors, administrators (or its successors and assigns in case of a corporation), discharges and pays all workers' compensation benefits with a personal injury date that occurs during the effective period of this bond, then, this bond shall be void. Otherwise this surety bond shall remain in full force and effect. Notwithstanding the number of claimants or the length of time this bond is in effect, there shall be only one surety bond amount and the aggregate liability of the surety shall not exceed the surety bond amount shown above. Page 1 of 3 (REV. 7/10) American LegalNet, Inc. www.FormsWorkFlow.com This bond may be cancelled at any time by the surety upon giving 60 days notice to the principal and the Agency. The liability of the surety shall terminate at the expiration of the 60 days except that the surety shall be liable for workers' compensation benefits with a personal injury date that occurs during the effective period of this surety bond, and before the 60 day expiration date. This surety bond shall be effective , 20 , until canceled. Surety Witness: Print Name: Title: Signature: Print Name: Title: ______ (Print name and address of Surety) Principal Witness: Print Name: Title: Signature: Print Name: Title: ____________________________________ ______ _______ _________________________________________ (Print name and address of Principal) Date: Page 2 of 3 (REV. 7/10) American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT AND ACKNOWLEDGMENT OF SURETY STATE OF _______________) COUNTY OF _______________) As a Notary Public, I certify that acting on behalf of the surety, personally appeared before me and that he or she is the , of _________ and that he or she is authorized to execute this surety bond pursuant to a power of attorney of the company that is dated _______ , a copy of which is attached; that the power of attorney has not been revoked; that the company has complied with all the requirements of law regulating the admission of such companies to transact business in the State of Michigan; and that the company is solvent and fully able to meet promptly all of its surety obligations. Subscribed and sworn to before me this _____ day of ______, 20___ ___________________________ (Notary Public) ________County, Michigan My commission expires __________. ACKNOWLEDGMENT OF PRINCIPAL STATE OF MICHIGAN ) COUNTY OF____________) Subscribed and sworn to before me this _____ day of ______, 20___ ___________________________ (Notary Public) ________County, Michigan My commission expires __________. Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com
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