I. Name of aupplicant. . (City, Street Number, Etc., Where Principal Office Located.) 2. Applicant's assets are of the value of $. Applicant's liabilities amount to $. A statement of the nature of applicant's assets and liabilities separately stated is filed herewith. 3. Applicant does not desire to insure the payment of compensation, etc., due his injured and dependents of his killed employes or to indemnify himself-itself against loss sustained by the direct payment thereof. 4. Applicant gives answer to the following questions, viz.: a. Do you maintain a hospital or hospitals in connection with your works or plant? Answer: b. If your answer be "Yes," give a description of such hospital or hospitals. Answer: C. Do you have in your employ one or more individuals whose regular duty it is to make daily inspection of your plant or works for the purpose of securing compliance with statutes or general orders of The Industrial Commission of Ohio relative to safety and sanitation? Answer: d. If your answer be "Yes," give the names and addresses of such person or persons. Answer: 5. Applicant asks that a finding of facts be made by the Commission authorizing-him-it-to pay compensation, etc., direct to-his-its -injured and the dependents of-his-its-killed employes in accordance with the provisions of the Workmen's Compensation Act, and hereby agrees to abide by all of the provisions of said act with reference to the payment or furnishing of such compensation, etc., and the rules and regulations with respect to the same adopted by the Commission. 6. (a) Applicant offers to file a bond conditioned in accordance with as surety thereon, in such sum, not less than $15,000.00 as the Commission may prescribe. (b) Applicant offers to deposit with the Treasurer of State, bonds of the United States, the State of Ohio, or of city, village, township, school district or other taxing districts of the state of Ohio, as follows, viz.: IN WITNESS WHEREOF.....have hereunto subscribed. ... .name .. (I or We.) (My or Our.) and caused our official seal to be affixed this.....day of. personally ...and.. who, being first duly sworn, declared that the facts set forth in the foregoing application are true. (My commission expires. (If the employer is a corporation, signature should be made and seal used according to the laws of Ohio, and the official taking this acknowledgement is cautioned to see that it is properly taken. Do not omit official titles of affiants if corporation.) THE INDUSTRIAL COMMISSION OF OHIO, COLUMBUS. NOTE. The following form of Bond is Prescribed for Employers who elect to pay Compensation, etc., direct, under the Provisions of Sec. 1465-69 G. C. (Sec. 22 of the Workmen's Compensation Law.) Guaranty Bond. of.. KNOW ALL MEN BY THESE PRESENTS: That.. as Principal, and. Ohio, (hereinafter called the Principal) of the State of (hereinafter called the Surety), as Surety, are held and firmly bound unto the State of Ohio for the use and benefit of the employes of the Principal in the sum of Fifteen Thousand ($15,000.00) Dollars, for the payment of which, well and truly to be made, the Principal binds itself, its successors and assigns, and the Surety binds itself and its successors and assigns, jointly and severally, firmly by these presents. WHEREAS, In accordance with the provisions of Section 22 of the Workmen's Compensation Act of Ohio, known as "An Act to further define the powers, duties and jurisdiction of the state liability board of awards, etc." (103 O, L., 72), the Principal has elected and been per mitted by The Industrial Commission of Ohio, by a finding of facts made in accordance with law, to pay individually to its injured employes, or to the dependents of its killed employes, compensation, and to furnish the medical, surgical, nursing and hospital services and attention and funeral expenses to them equal to or greater than is provided by the terms of said act; Now, THEREFORE, the condition of this obligation is such that if the said Principal shall pay, according to the terms, provisions and limitations of said act, to its injured employes or the dependents of its killed employes, compensation, and shall furnish medical, surgical, nursing and hospital services and attention and funeral expenses equal to or greater than is provided for in said act, then this obligation shall be null and void, otherwise to remain in full force and effect, subject, however, to the following express conditions: I. The liability of the Surety is limited to the payment of said compensation, and the furnishing of such medical, surgical, nursing and hospital services and attention and funeral expenses for injury or death occurring to employes of the Principal, in the course of their employment, within the period of twelve (12) months from and after the date hereof, subject to continuation and cancellation as hereinafter provided, and in no event shall the total liability of the Surety exceed the penal amount herein stated, to-wit, the sum of Fifteen Thousand ($15,000.00) Dollars. 2. This bond may be continued from year to year by a continuation- certificate, duly executed by the Surety, and when so continued, the total liability of the Surety shall be in all respects the same as if this bord had been originally written to include the period or periods for which it shall have been continued. 3. This bond and its continuation certificate, if any, may be cancelled at any time by the Surety upon giving thirty (30) days' written notice to The Industrial Commission of Ohio, in which event the liability of the Surety, shall, at the expiration of said thirty days, cease and determine, except as to such liability of the Principal on account of injury or death to any of its employes, as may have accrued prior to the expiration of said thirty days, it being understood that the Surety shall be liable, within the penal sum mentioned herein, for the default of the Principal in fully discharging any liability on his part accruing during the life of this obligation. IN TESTIMONY WHEREOF, Said Principal and said Surety have caused this instrument to be signed by their respective duly authorized officers and their corporate seals to be hereunto affixed this........day of.......... ...., 191.... Signed, sealed and delivered in presence of By..... Principal. By.. Surety. AUTHORIZATION FOR THE CONVERSION OF BONDS, DEPOSITED WITH THE TREASURER OF STATE, INTO MONEY TO PAY DEFAULTED COM PENSATION, ETC. KNOW ALL MEN BY THESE PRESENTS, That. ...of..... an employer of labor in the state of Ohio subject to the terms of what is commonly known as the workmen's compensation law of said state, desiring to elect to pay compensation direct to injured and dependents of killed employes, according to the provisions of Section 1465-69 G. C.,-hashave this day deposited with the Treasurer of State of Ohio the following bonds, viz.:.. being of the par value of $. as security for the payment of such compensation and for the benefit of such employes or their dependents. And said.... .hereby authorizes and directs The Industrial Commission of Ohio, or its successors in office, to convert any or all of said bonds into money and to use the same for the payment of any claim or claims for compensation, and to furnish. medical, surgical, nursing and hospital attention and medicines, funeral expenses, etc., to injured or dependents of killed employes in the event. the said.... ...shall make default in the payment of the same; and the judgment of said commission, or its successor in office, as to the necessity of converting said bonds into money for the aforesaid purpose, shall be final. It is understood that so long as said.... shall perform the obligations it has assumed under the workmen's compensation law to pay compensation and to furnish medical, surgical, nursing and hospital attention and medicines, funeral expenses, etc., direct to hisits their — injured and dependents of his its their killed employes that said bonds shall remain in the custody and care of the Treasurer of State and that said.... may receive from said Treasurer of State the interest coupons on said bonds as they become due and payable and that upon said. .ceasing to pay compensations, etc., direct to injured and dependents of killed employes under authority of The Industrial Commission of Ohio, or its successor in office, said bonds, or such part of the same as have not been converted into money as herein authorized, shall be returned to-him-it-them-by The Treasurer of State upon a certificate being filed with him by said Industrial Commission of Ohio, or its successor in office, to the effect that said... . . .....has fully complied with the law relating to workmen's compensation and has fully compensated all of his—its— their injured and dependents of-his-its-their-killed employes entitled to compensation, etc., under the terms of the workmen's compensation law; or has given surety to the satisfaction of said commission, or its successor in office, that-he-it-they-will do so. |