Surety Bond Instructions

  • This form can be used by companies newly approved for self-insurance or by companies replacing the security presently on file.
  • Deviations from this form are not permitted.
  • All companies covered by a company’s self-insurance must be named as “employers” on the bond form. If the parent company and its subsidiaries/affiliates are self-insured under the parent’s name, it is required that the language “and self-insured subsidiaries and affiliates, if any” be placed after the parent company’s name in the “employers” section. It is no longer permissible to list individual subsidiaries and affiliates.
  • The “Effective Date” on page 1 should be the date the bond was effective on the books of the company issuing it.
  • In the third paragraph of page 1, the date requested as the date, “the State Board of Workers’ Compensation entered an order”, is the date the State Board issued its initial Order granting an employer the privilege to be self-insured.
  • In Item 2 of page 2, the date requested should be the date the bond was effective on the books of the company issuing it and should be the same as the “Effective Date” on page number 1.
  • The amount of the bond should be the amount required by the State Board of Workers’ Compensation which was stated on an Order of the State Board.
  • Revisions to a bond presently on file can be done using a rider or endorsement.
  • The surety bond company issuing the bond must have an A.M. Best rating of "A" or better in order to be acceptable.