Third Party Prescription Administrator Bond Form - Illinois Department Of Insurance printable pdf download

Illinois Department of Insurance

320 West Washington Street

Springfield, IL 62767-0001

Third Party Prescription Administrator Bond

Co. Code # ________________

Bond # ___________________

Tax # _____________________

KNOW ALL MEN BY THESE PRESENTS, THAT I ______________________________________________

of __________________________________________________________________, a Third Party Administrator

____________________________________________________________________________, as principal and

__________________________________________________________ a company duly authorized to transact

surety business in the State of Illinois, are held and firmly bound unto the People of the State of Illinois and payable

to any party injured under the terms and conditions of this bond, in the full and penal sum of ___________________

dollars lawful money of the United States of America, for the payment of which, well and truly to be made, we bind

ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents.

THE CONDITION OF THIS OBLIGATION IS SUCH that the above bonded Principal is now or is about to

become licensed to engage or continue in the business of a Third Party Prescription Administrator as provided by

the Illinois Insurance Code, as amended.

NOW, THEREFORE, if the said Principal shall, while this bond is in force and effect make a full accounting and

due payment to the person or company entitled thereto of funds coming into his possession as an incident to

transactions under this license, and shall comply with all the provisions of the "Third Party Prescription Program

Act," then this obligation shall be null and void; otherwise to remain in full force and effect.

PROVIDED, HOWEVER, that this bond shall be continuous in form and may be terminated by the Surety, upon

its giving thirty (30) days notice of its intention of termination, such notice to be filed with the Director, Department of

Insurance, Springfield, Illinois.

IN WITNESS WHEREOF, the said principal has hereunto set his hand and seal, and the said surety has

caused these presents to be signed by its duly authorized officers and its corporate seal to be hereto affixed this

_________ day of _____________________, 20______.

(Principal)

(Bonding Company)

(Social Security Number)

(Officer)

(Attorney-in-Fact)

Important Notice: Under the Illinois Revised Statutes' insurance laws, disclosure of this information is voluntary; however, failure to comply

may result in this form not being processed. This form has been approved by the Forms Management Center.

Rev. 5/09

Third Party Prescription Administrator Bond

Third Party Prescription Administrator Bond Form - Illinois Department Of Insurance