Free Form SI-03 Attachment - Kentucky

COMMONWEALTH OF KENTUCKY DEPARTMENT 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, DEPARTMENT 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 except as herein expressly stated. This rider is effective __________________________________________________________________________________________________ Signed and sealed this _________ day of _____________________________, 20______.

___________________________________________________

PRINCIPAL
BY: ___________________________________________________ ___________________________________________________ SURETY

BY: ___________________________________________________