Kentucky > Workers Comp
Surety Rider - Kentucky
| Surety Rider Form. This is a Kentucky form and can be used in Workers Comp . |
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COMMONWEALTH OF KENTUCKY OFFICE OF WORKERS' CLAIMS FRANKFORT, KENTUCKY 40601 ATTACHMENT TO FORM NO. SI-03, 1/2004 SURETY RIDER TO BE ATTACHED TO AND FORM A PART OF BOND NUMBER _________________________________ EXECUTED BY _______________________________________________________________, AS PRINCIPAL, AND BY ________________________________________________________________________, AS SURETY, IN FAVOR OF THE COMMONWEALTH OF KENTUCKY, OFFICE OF WORKERS' CLAIMS; (INCREASE/DECREASE) THE AMOUNT OF SAID BOND FROM: ___________________________________________________ TO: ______________________________________________________ The Surety agrees that the obligation of this endorsement and the above -referenced bond shall cover and extend to all past, present, future and potential Kentucky workers' compensation liabilities of Principal, as a self-insured employer, to the sum herein named. Nothing herein contained shall vary, alter or extend any provision or condition of the original bond exce pt as herein expressly stated. This rider is effective __________________________________________________________________________________________________ Signed and sealed this _________ day of _____________________________, 20______. ___________________________________________________ PRINCIPAL BY: ___________________________________________________ ___________________________________________________ SURETY BY: ___________________________________________________ American LegalNet, Inc. www.USCourtForms.com
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