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Documents
Instructions
Updated: 2/2020
Refer to the Resident Fund Surety Bond Sample Form (PDF) as the letters correspond to the detailed instructions.
Detailed Instructions
§ Bond Number — Enter the number assigned to the bond by the insurer.
§ Amount — Enter the bond amount.
County of — Enter the county.
§ Effective Date — Enter the effective date of the bond (must be prior to or the date of contract beginning, if new ownership).
Name of Legal Entity — Enter the same corporate or management company name as on the contract with this department.
Name of Facility — Enter the exact name of the facility as listed on the contract.
Vendor Number — Enter the four- to six-digit number, i.e., 4030 or 403000 (owner number -2, not necessary).
Street Address — Enter the physical street address of the nursing facility.
City, State and ZIP Code — Enter the city, state and ZIP code for the physical address of the facility.
That we, — Enter the same corporate or management company name as on the contract with this department.
And surety company — Enter the name of the insurance company issuing the bond.
State of — Enter the state in which the insurance company is located.
Sum of $ — Enter the amount of the bond. Should be as much as the largest amount in the trust fund account on any given day of the month.
In witness whereof . . . — Enter the day, month and year of the bond.
Name of Surety — Enter the name of the insurance company issuing the bond.
Attorney in Fact — Original signature of the person designated Attorney-in-Fact on the Power of Attorney (Xerox or fax copies cannot be accepted).
Address of Surety — Enter the city, state and ZIP code of the insurance company.
Name of Principal — Enter the same corporate or management company name as on the contract with this department.
By Agent of Principal — Original signature of the officer representing the corporate or management company. If signed by anyone else, their title must also be included (Xerox or fax copies of the signature cannot be accepted).
Address of Principal — Enter the street (or P.O. Box), city, state and ZIP code of the corporate or management company headquarters.
Schedule A
1. Name of Principal — Enter the same corporate or management company name as on the contract with this department.
Agent of Principal — Original signature of the officer representing the corporate or management company. If signed by anyone else, their title must also be included (Xerox or fax copies of the signature cannot be accepted).
Address of Principal — Enter the street (or P.O. Box), city, state and ZIP code of the corporate or management company headquarters.
2. Name of Surety — Enter the name of the insurance company issuing the bond.
Attorney in Fact — Original signature of the person designated Attorney-in-Fact on the Power of Attorney (Xerox or fax copies of the signature cannot be accepted).
Address of Surety — Enter the city, state and ZIP code of the insurance company.
3. Name of Facility — Enter the exact name of the facility as listed on the contract.
4. Date of Execution of bond between Principal and Surety – Enter the day, month and year.
5. In the one-year period preceding . . . — Enter the maximum dollar amount that was in the trust fund account on any given day of the year preceding the date of the bond.
6. For the one-year period following . . . — Enter the largest dollar amount estimated that will be in the trust fund account on any given day in the coming year.
7. The greater of the two dollar amounts — Leave this field blank.
Original Power of Attorney MUST be attached.