Form DWC230 "Surety Bond for Assumed Certified Self-insurance Liabilities" - Texas

What Is Form DWC230?

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 March 1, 2014;
  • 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 DWC230 by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form DWC230 "Surety Bond for Assumed Certified Self-insurance Liabilities" - 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 78744-1645
(512) 804-4775
FAX (512) 804-4776
www.tdi.texas.gov
SURETY BOND
Bond Number
for Assumed Certified Self-Insurance Liabilities
KNOW ALL PERSONS BY THESE PRESENTS, THAT WE
a
Name of Principal
(State)
corporation with its principal place of business in the City of
, State
(City)
of
, as Principal, and
(State)
(Name of Surety)
, a
corporation, authorized to do business in
(State)
Texas, as Surety, are held and firmly bound unto the Commissioner of Workers’ Compensation for the
Obligations and Liabilities assumed by the Principal
as a
and initially incurred by the Certificate Holder
Certified Self-Insurer under the Texas Workers' Compensation Act in the sum of
(Written Amount)
Dollars ($
), lawful money
(Written Amount)
(Decimal Amount)
of the United States, for the payment of which sum we bind ourselves, our successors and assigns,
jointly and severally, firmly by these presents.
In this Bond, these terms have the following meanings:
1.
“Act” refers to the Texas Workers' Compensation Act; Texas Labor Code, Title 5, Subtitle A.
2.
“Rules” refers to the adopted administrative rules of the Texas Department of Insurance, Division
of Workers’ Compensation.
3.
"Certificate Holder" refers to the former "certified self-insurer," as that term is specified in Texas
Labor Code §407.065, under the Certificate of Authority(ies) issued by the Division under the
name(s) of:
(Specify CSI, including all subsidiaries included on any Certificate)
4.
"Commissioner" refers to the Commissioner of Workers’ Compensation as specified in the Act.
5.
“Division” refers to the Division of Workers’ Compensation.
6.
“Bond” means this Surety Bond and all riders and amendments thereto accepted by the
Commissioner in accordance with the terms hereof.
7.
“Penal Sum” refers to the dollar amount of this Bond.
DWC-230 (Rev.03/14)
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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 78744-1645
(512) 804-4775
FAX (512) 804-4776
www.tdi.texas.gov
SURETY BOND
Bond Number
for Assumed Certified Self-Insurance Liabilities
KNOW ALL PERSONS BY THESE PRESENTS, THAT WE
a
Name of Principal
(State)
corporation with its principal place of business in the City of
, State
(City)
of
, as Principal, and
(State)
(Name of Surety)
, a
corporation, authorized to do business in
(State)
Texas, as Surety, are held and firmly bound unto the Commissioner of Workers’ Compensation for the
Obligations and Liabilities assumed by the Principal
as a
and initially incurred by the Certificate Holder
Certified Self-Insurer under the Texas Workers' Compensation Act in the sum of
(Written Amount)
Dollars ($
), lawful money
(Written Amount)
(Decimal Amount)
of the United States, for the payment of which sum we bind ourselves, our successors and assigns,
jointly and severally, firmly by these presents.
In this Bond, these terms have the following meanings:
1.
“Act” refers to the Texas Workers' Compensation Act; Texas Labor Code, Title 5, Subtitle A.
2.
“Rules” refers to the adopted administrative rules of the Texas Department of Insurance, Division
of Workers’ Compensation.
3.
"Certificate Holder" refers to the former "certified self-insurer," as that term is specified in Texas
Labor Code §407.065, under the Certificate of Authority(ies) issued by the Division under the
name(s) of:
(Specify CSI, including all subsidiaries included on any Certificate)
4.
"Commissioner" refers to the Commissioner of Workers’ Compensation as specified in the Act.
5.
“Division” refers to the Division of Workers’ Compensation.
6.
“Bond” means this Surety Bond and all riders and amendments thereto accepted by the
Commissioner in accordance with the terms hereof.
7.
“Penal Sum” refers to the dollar amount of this Bond.
DWC-230 (Rev.03/14)
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SURETY BOND - DWC230
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8.
“Security Deposit” refers to the security (Surety Bond, irrevocable letter of credit, cash, or
negotiable securities of the United States or Texas) provided by the Principal to the Commissioner
to guarantee its Obligations and Liability.
9.
“Texas Certified Self-Insurer Guaranty Association” refers to the quasi-governmental entity
governed by Subchapter G, Chapter 407, Texas Labor Code.
10. "Declaration of Impairment" refers to a written determination by the Commissioner that the
Principal or its agent has become an impaired withdrawn self-insurer:
• who has suspended payment of workers’ compensation,
• who has filed for relief under bankruptcy laws,
• against whom bankruptcy proceedings have been filed, or
• for whom a receiver has been appointed by a court of competent jurisdiction;
as these criteria for impairment are described or referenced in Texas Labor Code §§407.001(3),
407.045, 407.124 and 28 Texas Administrative Code §§114.2 and 114.14.
11. “Bond Call” refers to the written demand by the Commissioner to secure the release of this Bond’s
proceeds.
12. “Bond Draw” refers to a partial payment by the Surety on the Penal Sum of this Bond in
accordance with the terms of this Bond.
13. “Cancellation” refers to the point in time at which the Principal and Surety are no longer incurring
Obligations and Liabilities under this Bond.
14. “Termination” refers to the full release of all Surety responsibility under this Bond.
15. "Obligations and Liabilities" means the amount equal to the sum of the amount of the liabilities for
the payment of outstanding workers' compensation claims, including claims incurred but not yet
reported, and the amount necessary to provide for the payment of the administration of those
claims, including legal costs and expenses, initially incurred by the Certificate Holder as Certified
Self-Insurer(s) under the Texas Workers' Compensation Act between
and
.
st
(Effective date of 1
Certificate)
(Last date of self-insurance coverage)
16. "Principal" refers to
(Name of Principal)
which has assumed the responsibilities and the Obligations and Liabilities of the Certificate Holder
as a withdrawn self-insurer.
WHEREAS, in accordance with the provisions of the Act and Rules, the Certificate Holder elected to
self-insure, and made application for, or received from the Division, Certificate(s) of Authority to Self-
Insure; and
WHEREAS, the Principal has assumed the responsibilities and the Obligations and Liabilities of the
Certificate Holder as a withdrawn self-insurer under the Act; and
WHEREAS, the Principal is required to furnish proof satisfactory to the Commissioner of its ability to
assure that all workers' compensation Obligations and Liabilities incurred by the Certificate Holder as a
certified self-insurer under the Act are promptly met.
DWC-230 (Rev.03/14)
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SURETY BOND - DWC230
Bond Number
NOW THEREFORE, the conditions of this Bond or obligation are such that if the Principal shall pay
and furnish compensation, pursuant to the terms, provisions, and limitations of the Act, then this Bond
shall not be liable for those liabilities, which have been paid by the Principal.
FURTHERMORE, it is understood and agreed that:
1.
Term of This Bond
This Bond shall be continuous in term and shall remain in full force and effect unless
terminated in the manner provided herein. This Bond and the Obligations and Liabilities in
this Bond shall otherwise remain and continue in full force and effect so long as the liability of
the Principal for the Obligations and Liabilities of the Certificate Holder exists under the Act.
2.
Scope of This Bond’s Coverage
The Surety undertakes and agrees that the obligation of this Bond shall cover and extend to all
Obligations and Liabilities of the Principal, as assuming those Obligations and Liabilities of
the Certificate Holder, under the Act to the extent of the Penal Sum herein named, without
regard to specific injuries, date or dates of injuries, happenings, or events. Obligations and
Liabilities are deemed hereby to be incurred on the date an injury is sustained by an employee
of the former Certificate Holder.
3.
Limitation of Liability on This Bond
The aggregate liability of the Surety shall not exceed the Penal Sum in any event except as
expressly stated in this Bond.
4.
Cancellation of This Bond
4.1. Scope of Cancellation - This Bond shall secure the payment of all Obligations and
Liabilities incurred by the Principal before the effective date of Cancellation. Cancellation of
this Bond does not alter or limit:
4.1.1. The Term of this Bond or
4.1.2. The responsibilities of the Surety under this Bond or
4.1.3. The Obligations and Liabilities incurred by the Principal before the effective date
of Cancellation.
4.2. Cancellation by Surety - The Surety may cancel this Bond by the Commissioner
receiving written notice of Cancellation from the Surety 60 days before the requested effective
date of Cancellation. The Commissioner will acknowledge the written notice and promptly
notify the Principal of the pending Cancellation date.
DWC-230 (Rev.03/14)
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SURETY BOND - DWC230
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4.3. Effect of Failure to Furnish a Replacement Security Deposit - Failure by the Principal to
furnish a replacement qualifying, acceptable Security Deposit in the full amount and in the
form as approved and required by the Commissioner within 10 working days after receiving
any notice of Cancellation by the Surety under section 4.2 of this Bond may result in a Bond
Call by the Commissioner under the provisions of this Bond. A "working day" is defined in 28
Texas Administrative Code §102.3(b).
4.4. Effective Cancellation Date - The effective cancellation date may be earlier than the 61st
day after the Commissioner receives written notice under Section 4.2; however, in no case will
it be later than the 61st day.
4.5. Notification by Commissioner – The Commissioner will provide the Surety and the
Principal written notification of the effective date of any Cancellation under Section 4 of this
Bond.
5.
Termination
5.1. Full Release of Surety - All of the Surety’s obligations under this Bond are terminated
whenever:
5.1.1. The Principal furnishes a replacement qualifying, acceptable Security Deposit(s)
in the full amount, and in the form as approved and required by the Commissioner, or
5.1.2. The Surety has paid the full Penal Sum of the Bond plus assessed legal costs, if
any.
5.2. Notification by Commissioner - The Commissioner will provide the Principal and the
Surety written notice of the effective Termination date of this Bond.
6.
Effective Dates and Times
6.1. Dates – For purposes of this Bond, the Commissioner shall count dates starting with the
first calendar day after receipt and approval.
6.2. Times - For purposes of this Bond, times are effective at 12:01 a.m.
7.
Return of Original Bond - Upon acceptance of a replacement Security Deposit(s), the
Commissioner will return the original Bond to the Principal.
DWC-230 (Rev.03/14)
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8.
Amendments to This Bond
8.1. If the Principal legally changes its name, this Bond shall be amended by rider or
endorsement to state the correct name of the Principal after such change in name. Such rider
or endorsement shall be executed by the Principal and Surety and delivered to the
Commissioner.
8.2. If the Principal amends its charter, articles of incorporation, or partnership agreement to
change its identity or business structure, or in any other manner materially alters its status as it
existed at the time of issuance of this Bond, the Principal shall, within 30 days after the
amendment or other action, notify the Commissioner in the form and manner prescribed by
the Commissioner and provide the Commissioner with a copy of such amendment or other
action. The Principal shall provide other required notices specified in 28 Texas Administrative
Code §114.13 as the entity assuming the Obligations and Liabilities of the former
Certificate Holder and shall comply with the requirements specified in 28 Texas
Administrative Code §§114.10 and 114.12.
8.3. If the Penal Sum of this Bond is increased or decreased to maintain an adequate Security
Deposit as required by the Act, this Bond shall be amended by rider or endorsement or revised
bond acceptable to the Commissioner and executed by the parties to reflect such increase or
decrease upon prior written approval of the Commissioner.
8.4. Except as provided (or set forth) in 8.2 above, no amendment of this Bond shall in any
way impair or limit the Obligations and Liabilities incurred under this Bond for the overall
coverage of said Principal.
9.
Impact of Changes in Law on This Bond
No change in Texas law, in the Act, or in the Rules, procedures, or organization of the
Division shall in any way impair or limit the responsibilities of this Bond, and the Division
shall not be required to notify the Surety of such changes in order for them to be effective.
10.
Applicable Law
This Bond shall be governed by, construed, and enforced in accordance with the laws of the
State of Texas. Venue for any action with respect to this Bond shall be in the state district
courts of Travis County, Texas. The Principal and Surety hereby consent to the personal
jurisdiction of the Travis County District Courts in any action taken on this Bond.
11.
Conflict between This Bond and Applicable Law
This Bond is submitted in connection with the self-insurance provisions of the Act and is
intended to be governed thereby. In the event of any conflict between this Bond and any
statute, rule, regulation, or other law; the statute, rule, regulation, or other law shall control
except for Bond Call and Bond Draw procedures otherwise specified in this Bond.
DWC-230 (Rev.03/14)
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