Form Hcs 402 - Home Care Organization Dishonesty Bond
Download a blank fillable Form Hcs 402 - Home Care Organization Dishonesty Bond in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Hcs 402 - Home Care Organization Dishonesty Bond with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES BUREAU
HOME CARE ORGANIZATION DISHONESTY BOND
(Original sent to the Home Care Services Bureau at 744 P Street, M.S. T8-3-90, Sacramento, CA 95814)
HOME CARE ORGANIZATION APPLICANT/LICENSEE (“LICENSEE”) NAME
HOME CARE ORGANIZATION APPLICANT/LICENSEE MAILING ADDRESS
CITY
STATE
ZIP CODE
SURETY COMPANY
AREA CODE/TELEPHONE
(
)
SURETY COMPANY ADDRESS
CITY
STATE
ZIP CODE
LOCAL AGENT NAME
AREA CODE/TELEPHONE
(
)
HOME CARE ORGANIZATION NAME (If doing business in name other than that of Applicant/Licensee above)
HOME CARE ORGANIZATION ADDRESS (If different from that of Applicant/Licensee) CITY
STATE
ZIP CODE
HOME CARE ORGANIZATION NUMBER (IF APPLICABLE)
BE IT KNOWN THAT:
Licensee, as Principal, and Bonding Company, as Surety, are held and firmly bound to the State of California for the use
and benefit of Licensee’s clients or members of their household (collectively referred to as “Clients”). In the amount of
, for the payment of which the Principal and Surety bind themselves, their respective
heirs, successors and assigns, jointly and severally;
WHEREAS Health and Safety Code Sections 1796.37(a)(4) and 1796.42(d) require certain applicants for license as a
Home Care Organization to maintain a bond against employee dishonesty that incudes third party coverage; and
WHEREAS the Licensee has applied to operate a Home Care Organization;
NOW, THEREFORE, the Surety is liable on this bond in the event that any Clients are damaged by any dishonest or
fraudulent act, including but not limited to theft, embezzlement, conversion or common law fraud or deceit by Principal or
the Principal’s employees.
Any Clients of the Principal, damaged as a result of the dishonest or fraudulent acts of the Principal or the Principal’s
employees, may file a claim with the Surety or bring an action in a proper court on the bond for the amount of damages
suffered thereby to the extent covered by the bond.
Regardless of the number of years this bond is in effect, the number of licensee renewal terms, the number of premiums
paid, or the number of claims made, the Surety’s aggregate liability shall not be more than the penal sum of this bond.
This bond may be canceled by the Surety in accordance with Code of Civil Procedure section 996.330, and notice of
cancellation must be sent in accordance with Code of Civil Procedure section 996.320 to the attention of the California
Department of Social Services, Home Care Services Bureau. This bond is effective as of (Date) ___________________,
and remains in effect as long as the license is valid.
I certify under penalty of perjury under the laws of the State of California.
SURETY COMPANY SIGNATURE
BOND NUMBER
DATE
NAME OF ATTORNEY IN FACT FOR SURETY COMPANY
SIGNATURE OF ATTORNEY IN FACT FOR SURETY COMPANY
PRINCIPAL
SIGNATURE OF PRINCIPAL
DATE
HCS 402 (12/15)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal