Fillable Printable Form 207-134-000

Form 207-134-000

F207-134-000 SU-5 bond r ider 10-00

STATE OF WASHINGTON

DEPARTMENT OF LABOR AND INDUSTRIES

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 STATE OF WASHINGTON, DEPARTMENT OF LABOR AND INDUSTRIES

In consideration of the mutual agreements herein contained, the Principal and the Surety hereby

consent to ( INCREASE / DECREASE ) the AMOUNT OF PENAL SUM OF SAID BOND

FROM:

TO:

The Surety undertakes and agrees that the obligation of this endorsement and the above

referenced bond shall cover and extend to all past, present, existing and potential liabilities of

said Principal, as a self-insurer, to the penal sum herein named, without regard to specific

injuries, date or dates of injuries, happenings or events. The aggregate liability for all acts and

defaults, whenever committed, shall in no event exceed the last sum named; it being the intent

hereof to preclude cumulative liability.

Nothing herein contained shall vary, alter or extend any provision or condition of this bond

except as herein expressly stated.

This rider is effective____________________________________________________________

Signed and sealed this ____________day of _________________________________________

PRINCIPAL

ACCEPTED BY:

DEPARTMENT OF LABOR AND INDUSTRIES

BY:

SURETY BY: Program Manager for Self-Insurance

BY:

DATE

RESET