Fill and Sign the Workers Compensation Surety Bond Oregon Form

STATE OF OREGON DEPARTMENT OF CONSUMER AND BUSINESS SERVICES Workers’ Compensation Division 350 Winter Street NE P.O. Box 14480 Salem, OR 97309-0405 SURETY BOND Bond number:             KNOW ALL BY THESE PRESENTS, THAT WE,                    with headquarters in the CITY OF              as Principal and         , an              Corporation authorized to transact surety business in Oregon, as “Surety,” hereby jointly and severally bind ourselves, our respective heirs, executors, administrators, successors and assigns firmly by these presents unto the State of Oregon, as Obligee, for the use and benefit of all subject workers of the Principal, and any entity that is or has been approved by the department for inclusion in and included in a self-insurance certification in which the Principal has been included (the Principal and such other entities, the “Covered Entities” or, in the singular, a “Covered Entity”), and persons who may be entitled to compensation under the Workers’ Compensation Law of the State of Oregon, and to the Department of Consumer and Business Services, Workers’ Compensation Division, of the State of Oregon for any assessments, contributions or other obligations due from a Covered Entity to the Department of Consumer and Business Services, Workers’ Compensation Division, in the penal sum of:             Dollars ( $             ), lawful money of the United States, assigns jointly and severally, firmly by these presents. Under this bond any failure, by any Covered Entity, to pay compensation or to pay any assessments, contributions or other obligations shall be considered a failure to pay by the Principal. THE CONDITION OF THE (FOREGOING) OBLIGATION OF THIS BOND IS SUCH that if the Principal which (i) is about to make application to become a certified self-insured employer or (ii) is a certified self-insured employer and desires to continue with self-insured status to carry its own risk, or (iii) has been in the past a self-insured employer, pays or causes to be paid: (a) all compensation for compensable injuries that may become due to subject workers and their beneficiaries of any Covered Entity; and (b) all assessments, contributions, and other obligations imposed on a Covered Entity that may become due from the Covered Entity to the Department of Consumer and Business Services, Workers’ Compensation Division under the Oregon Workers’ Compensation Law, then this obligation shall be void; otherwise to remain in full force and effect. In the event any Covered Entity fails to pay compensation that becomes due to any subject worker or beneficiary, or any assessments, contributions or other obligations that become due to the Department of Consumer and Business Services, Workers’ Compensation Division under law, then the Surety will be obligated to pay the compensation, assessments, contributions, and other obligations. The liability of the Surety shall not be affected by the Principal’s failure to sign this bond. Nonpayment of the bond premium will not invalidate this bond nor shall the State of Oregon or the Department of Consumer and Business Services, Workers’ Compensation Division of the State of Oregon be obligated for the payment of any premiums. 440-824 (1/17/DCBS/WCD/WEB) Continued SURETY BOND — continued IT IS FURTHER UNDERSTOOD AND AGREED that the following conditions shall also apply to this surety bond: 1. The Surety undertakes and agrees that the obligation of this bond shall cover and extend to all past, present, existing, and potential liability of any Covered Entity, including the Principal’s liability and obligations for any Covered Entity, to the extent of the penal sum herein named, without regard to specific injuries, date or dates of injuries, happenings, or events. It is provided, however, that this undertaking, and the obligation of this bond, shall apply only to worker’s claims for compensation and to the department’s claims for assessments, contributions or other obligations arising under the Workers’ Compensation Law, that result from or arise out of an occurrence that takes place on or after:       through the date of termination of this surety bond or cancellation or revocation of the Principal’s self-insurance certification. For the purpose of this paragraph, an occurrence is an event, circumstance, or exposure to conditions of any character that results in a compensable claim of any sort under the Workers’ Compensation Law or which gives rise to an obligation to satisfy any assessments, contributions, or obligations under the Workers’ Compensation Law. 2. In the event any Covered Entity fails to pay compensation that becomes due to any subject worker or beneficiary of a subject worker covered by a Covered Entity’s self-insurance certification within ten (10) days after the same becomes or become due, or any assessments, contributions or other obligations that become due to the Department of Consumer and Business Services, Workers’ Compensation Division under law, then the Surety will be obligated to pay the compensation, assessments, contributions and other obligations. The Surety shall forthwith pay to the extent of its liability under this bond, the Covered Entity’s liabilities and obligations as directed by the Department of Consumer and Business Services, Workers’ Compensation Division, including reimbursement of payments the department has made or makes to parties entitled thereto, upon the order of the Department of Consumer and Business Services, Workers’ Compensation Division. 3. If a Covered Entity shall suspend payment or shall become insolvent or a receiver shall be appointed for its business, the undersigned Surety will be obligated to pay the compensation, assessments, contributions and other obligations, to the extent of its liability under this bond, before the expiration of ten (10) days after the same becomes due, as directed by the Department of Consumer and Business Services, Workers’ Compensation Division, including reimbursement of payments the department has made or makes to parties entitled thereto upon the order of the Department of Consumer and Business Services, Workers’ Compensation Division, without regard to any proceedings for liquidation of the Covered Entity. 4. The undersigned are also held and firmly bound for the payment of all legal costs and expenses, including reasonable attorney fees incurred in any and all actions and proceedings taken to enforce payment of this bond, or payments of any award or judgment rendered against the undersigned Surety, on account of the Surety’s execution of this bond. 5. By endorsement the parties may agree, subject to the approval of the Department of Consumer and Business Services, Workers’ Compensation Division, to increase or decrease the penal sum of the bond, without impairing the obligation under this bond for the overall coverage of all Covered Entities for all past, present, existing and potential liability, as a certified self-insured employer without regard to specific injuries, date or dates of injuries, happenings, or events from the date in condition No. 1 above, through the date of termination of this surety bond, cancellation or revocation of the Principal’s self-insured certification to the extent, in the aggregate, of the penal sum as increased or decreased. 6. This surety bond may be terminated by the Surety by giving to the Director of the Department of Consumer and Business Services, Workers’ Compensation Division, and the Principal written notice stating that on a date not less than thirty (30) days after the date the notice is received by the Director, such termination shall be effective. Such termination shall in no way limit the liability of Surety for subsequent defaults of a Covered Entity’s obligations incurred under the Workers’ Compensation 440-824 (1/17/DCBS/WCD/WEB) Continued SURETY BOND — continued Law prior to the effective date of such termination. It is provided, however, that the liability of the Surety under this bond may be discharged in the event that: (a) the Principal files substitute surety, accepted by the Director as substitute surety for this surety bond, covering all past, present, existing and potential liability of Covered Entities under the Workers’ Compensation Law in an amount required by the Director; and (b) this surety bond is released as documented in writing from the Department of Consumer and Business Services, Workers’ Compensation Division. 7. The Surety’s obligations under this surety bond shall not be affected by the existence, validity, enforceability, perfection or extent of any other security or collateral deposited or otherwise made available by or on behalf of the Principal or any Covered Entity, whether under ORS 656.407(2), OAR 436-050-0165 or otherwise, to secure the Principal’s or Covered Entity’s obligation to make payment of compensation and to make payment of other payments, assessments, contributions or other obligations that become due to the Director of the Department of Consumer and Business Services or to the Department of Consumer and Business Services, Workers’ Compensation Division, under the Workers’ Compensation Law. The Surety agrees that the Director and the Department of Consumer and Business Services, Workers’ Compensation Division, may resort to this surety bond for payment of any compensation and for payments of any other payments, assessments, contributions or other obligations that become due, whether or not they shall have resorted to any other security or collateral therefor, or shall have proceeded against a Covered Entity for such payment or payments. The Surety agrees that the Director and the Department of Consumer and Business Services, Workers’ Compensation Division, may in their sole and absolute discretion elect to pursue or resort to any available source, security or collateral (including this surety bond) at any time, and in any order or combination, for payment of any compensation and for payments of any other payments, assessments, contributions or other obligations that become due, with respect to any Covered Entity, under the Workers’ Compensation Law. PROVIDED, the Surety herein, by and in the execution of this bond, does hereby recognize that said bond is a direct financial guarantee to and for the benefit of all subject workers and their beneficiaries of            and any Covered Entity and to and for the benefit of the Department of Consumer and Business Services, Workers’ Compensation Division, of the State of Oregon.PROVIDED FURTHER, THIS BOND SHALL BE EFFECTIVE AS OF       , 20        Signed, sealed, and delivered this       day of              , 20      PRINCIPAL : PRINCIPAL:                 Signature Signature               Name and title Name and title PRINCIPAL:       Signature       Name and title ATTEST: SURETY:           Secretary signature Signature       440-824 (1/17/DCBS/WCD/WEB) Name and title Continued SURETY BOND — continued Accepted , but not as a substitute surety bond, this        day of         , 20       Department of Consumer and Business Services, Workers’ Compensation Division of the State of Oregon, Obligee Signature       Name and title OR ACCEPTED , as a surety bond, this        day of       , 20       Department of Consumer and Business Services, Workers’ Compensation Division of the State of Oregon, Obligee Signature           Name and title OR Accepted , as a substitute surety bond for all previous bonds this       day of           , 20        Department of Consumer and Business Services, Workers’ Compensation Division of the State of Oregon, Obligee Signature       Name and title 440-824 (1/17/DCBS/WCD/WEB)