Fill and Sign the Si Guaranty Bond for Workers Compensation Arizona Form

Bond No.                              That       of       and       of       sum of       Dollars, ($       STATE OF ARIZONA THE INDUSTRIAL COMMISSION OF ARIZONA ) ) ) IN THE MATTER OF THE APPLICATION OF ) ) ) ) ) Employer, for a Certificate of Authorization to Self-Insure ) ) ) SELF-INSURANCE GUARANTY BOND WORKER'S COMPENSATION LAW KNOW ALL MEN BY THESE PRESENTS: , as Principal, I , an Insurance Company duly authorized and licensed to transact the business of fidelity and surety insurance in the State of Arizona, as surety, are held and firmly bound unto The Industrial Commission of Arizona, for the use and benefit of each and all the employees of the Principal, including their dependents, and The Industrial Commission of Arizona, in the ) for the payment of which, well and truly to be made, the Principal binds itself, its heirs, executors, administrators, successors and assigns, and the Surety binds itself, its successors and assigns, jointly and severally by these presents: WHEREAS, in accordance with the provisions of A.R.S. Section 23-961, relating to the provisions of the Arizona Workers' Compensation Law, the Principal has elected to self-insure, and has applied to The Industrial Commission of Arizona for a certificate of authorization to self-insure; NOW, THEREFORE, the conditions of this obligation are such that if the said Principal shall pay and furnish compensation and medical and hospital benefits pursuant to the terms, provisions and limitations of said law, to its injured employees and to the dependents of its killed employees, then this obligation shall be null and void, otherwise to remain in full force and effect, subject, however, to the following express conditions: 1. The liability of the Surety under this obligation shall be the same as the continuing liability of the Principal for the payment of assessments and the payment and furnishing of said compensation and medical, hospital and surgical benefits for injuries and/or death occurring to employees of the Principal within the period of twelve (12) months from and after the date hereof, whether or not the liability for payment accrues during the twelve month period from and after the date hereof, but in no event shall the total liability of the Surety exceed the penal amount heretofore stated herein. 2. It is expressly understood and agreed that in the event said Principal shall suspend payment or shall become insolvent or a receiver shall be appointed for its business and the said Principal shall fail to pay any Award or Awards or Orders that shall be rendered against it by The Industrial Commission of Arizona, within thirty (30) days after the same becomes or become final, said Surety shall forthwith pay to the extent of its liability under this bond said determinations, Award, Awards or Orders upon the Order of The Industrial Commission of Arizona without regard to any proceedings for liquidation of said Principal. Form ICA 02-0060-80 (Rev. 88) the respective parties thereunto duly authorized this                               By                         By             Countersigned at                         By       3. The undersigned are held and firmly bound for the payment of all legal costs, including reasonable attorney fees, incurred in all or any actions or proceedings taken to enforce payment of this bond, or payment of any Award or Judgment rendered against the undersigned Surety, on account of the execution by it of this bond. IN WITNESS WHEREOF, the parties hereto have caused their names to be signed and this instrument to be sealed byday of 20 (Date of Self Insurance Authorization) ATTEST: Principal (SEAL) Secretary (Name) (Title ) ATTEST: Surety (SEAL) Secretary (Name) (Title) , Arizona, this day of , 20 Agent Note: Certified copy of Power of Attorney authorizing execution of this bond by the Surety to be attached hereto.