STATE OF MARYLAND WORKERS’ COMPENSATION COMMISSION 10 E. BALTIMORE STREET BALTIMORE, MARYLAND 21202 IRREVOCABLE LETTER OF CREDIT Name of Self-Insurer/Applicant: Irrevocable Letter of Credit Number: Self-Insured Company Name: Effective Date: Self Insured Address: Amount : $ Expiration : Beneficiary Maryland Workers’ Compensation Commission 10 East Baltimore Street Baltimore, MD 21202 Dear Sir or Madam: We have established this irrevocable letter of credit solely in your favor for drawings up to United States $ effective at Issuer name Street,suite,etc. City, State, ZIP code Telephone and expiring with our close of business on . We hereby undertake to promptly honor your sight draft(s) drawn on us, indicating our letter of credit no. , for all or any part of this letter of credit if presented at our office specified in paragraph one above on or before the expiration date or any automatically extended date. Except as stated herein, this undertaking is not subject to any condition or qualification. The obligation of the under this Letter of Credit shall be the individual obligation of the in no way contingent upon reimbursement with respect thereto. CLICK HERE TO CLEAR THE FORM MD WCC A-08 (09/2006) 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com STATE OF MARYLAND WORKERS’ COMPENSATION COMMISSION 10 E. BALTIMORE STREET BALTIMORE, MARYLAND 21202 The stated conditions of this letter of credit are: 1. This letter of credit shall be deemed automatically extended without amendment for one year from the expiration date hereof, or any future expiration date, unless at least (60) days prior to any expiration date we shall notify you in writing sent by registered mail or overnight courier that we elect not to consider this letter of credit extended for any such additional period. 2. If this letter of credit expires during an interruption of business as described in Article 17 of said publication 500, the bank hereby specifically agrees to effect payment if this credit is drawn against within 30 days after the resumption of business. All drafts drawn under this letter of credit must be marked “drawn under Letter of Credit No. dated .” This letter of credit shall be governed by the laws of Maryland and subject to the uniform customs and practice for documentary credits, 1993 revision, ICC publication number 500 (“UCP”) and in the event of any conflict the laws of Maryland will control. If any legal proceedings are initiated with respect to payment of this Letter of Credit, it is agreed that such proceedings shall be subject to the laws of Maryland and the jurisdiction of Maryland courts. If you require any further assistance or have any questions regarding this transaction, please contact: Name Authorized Signature Title: Telephone No. Email address: CLICK HERE TO CLEAR THE FORM MD WCC A-08 (09/2006) 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com