Form DWC216 "Surety Bond Name Change Rider" - Texas

What Is Form DWC216?

This is a legal form that was released by the Texas Department of Insurance - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2006;
  • The latest edition provided by the Texas Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DWC216 by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form DWC216 "Surety Bond Name Change Rider" - Texas

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TEXAS DEPARTMENT OF INSURANCE
Division of Workers’ Compensation
Self-Insurance Regulation, MS-60
7551 Metro Center Dr., Ste 100, Austin, Texas 78744-1609
(512) 804-4775 FAX (512) 804-4776
SURETY BOND NAME CHANGE RIDER
Bond No.
WHEREAS, Surety Bond No.
submitted to and accepted by the
Commissioner of the Division of Workers’ Compensation, which Bond named
as Principal and
(Principal Company Name)
as Surety; and
(Surety Company Name)
WHEREAS, the Principal has changed its name from
(Previous Principal Company Name)
to
.
(Current Principal Company Name)
It is understood and agreed that said name change shall be effective in accordance with
the terms and conditions of said Bond for all past, present, existing and potential liability of the
Surety for said Principal, as a certified self-insurer, without regard to specific injuries, date or
dates of injuries, happenings or events.
It is further agreed and understood that this Bond rider shall be attached to and form a
part of Bond No.
, the Principal and the Surety hereby reaffirming all of their
obligations and liabilities under said Bond as modified by this rider.
Signed, sealed, and delivered this
day of
,
.
FOR SURETY
Signature: Attorney In-Fact and/or Authorized Representative
Business Name
Printed Name/Title
Business Address
Telephone Number
City/State/Zip
ATTEST
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Corporate Secretary of Surety
Printed Name
DWC-216 (Rev. 1/06)
1 of 2
TEXAS DEPARTMENT OF INSURANCE
Division of Workers’ Compensation
Self-Insurance Regulation, MS-60
7551 Metro Center Dr., Ste 100, Austin, Texas 78744-1609
(512) 804-4775 FAX (512) 804-4776
SURETY BOND NAME CHANGE RIDER
Bond No.
WHEREAS, Surety Bond No.
submitted to and accepted by the
Commissioner of the Division of Workers’ Compensation, which Bond named
as Principal and
(Principal Company Name)
as Surety; and
(Surety Company Name)
WHEREAS, the Principal has changed its name from
(Previous Principal Company Name)
to
.
(Current Principal Company Name)
It is understood and agreed that said name change shall be effective in accordance with
the terms and conditions of said Bond for all past, present, existing and potential liability of the
Surety for said Principal, as a certified self-insurer, without regard to specific injuries, date or
dates of injuries, happenings or events.
It is further agreed and understood that this Bond rider shall be attached to and form a
part of Bond No.
, the Principal and the Surety hereby reaffirming all of their
obligations and liabilities under said Bond as modified by this rider.
Signed, sealed, and delivered this
day of
,
.
FOR SURETY
Signature: Attorney In-Fact and/or Authorized Representative
Business Name
Printed Name/Title
Business Address
Telephone Number
City/State/Zip
ATTEST
(
A
f
f
i
x
S
e
a
l
H
e
r
e
)
(
A
f
f
i x Seal
x
S
e
a
l He e e )
H
e r
r
)
(Affi
Corporate Secretary of Surety
Printed Name
DWC-216 (Rev. 1/06)
1 of 2
SURETY BOND NAME CHANGE RIDER
Bond No.
Rider Date
FOR PRINCIPAL
Signature: Attorney In-Fact and/or Authorized Representative
Business Name
Printed Name/Title
Business Address
Telephone Number
City/State/Zip
ATTEST
(
A
f
f
i
x
S
e
a
l
H
e
r
e
)
( ( Affi
A
f
f
i x Seal
x
S
e
a
l He e e )
H
e r
r
)
Corporate Secretary of Principal
Printed Name
DWC-216 (Rev. 1/06)
2 of 2
Page of 2