FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF-INSURANCE SECTION SELF-INSURER'S IRREVOCABLE LETTER OF CREDIT IRREVOCABLE LETTER OF CREDIT NO.____________________ APPLICANT NAME:______________________________ APPLICANT ADDRESS:___________________________ BENEFICIARY NAME:____________________________ BENEFICIARY ADDRESS:_________________________ Dear Sir/Madam: We, _______________, hereinafter "Bank", hereby establish this Irrevocable Letter of Credit solely in your favor for drawing up to U.S. $___________________________effective immediately. This Irrevocable Letter of Credit is issued, presentable and payable at our office at____________________________________________________________________________ _________, and expires with our close of business on ______________________. We hereby undertake to promptly honor your sight draft(s) drawn on us indicating our Irrevocable Letter of Credit No. __________________for all or any part of this Irrevocable Letter of Credit if presented at: ____________________________________________________, on or before the expiration date or any automatically extended date. All sight drafts for all or any part of this Irrevocable Letter of Credit shall be promptly honored without any further condition, and no documentation other than such sight draft(s) shall be required as a condition of honor. Except as stated herein, this understanding is not subject to any agreement, condition or qualification. The obligation of the Bank under this Irrevocable Letter of Credit shall be the individual obligation of the Bank, and is no way contingent upon reimbursement with respect thereto. It is a condition of this Irrevocable Letter of Credit that it shall be deemed automatically extended without amendment for one year from the expiration date hereof, and all future expiration dates, unless ninety (90) days prior to any expiration date, we notify you by Certified Mail, return receipt requested, or courier, that we elect not to consider this Irrevocable Letter of Credit renewed for any such additional period. FORM DFS-F2-SI-6 (8/2009) Rule 69L-5.218, F.A.C. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com It is a further condition of the Irrevocable Letter of Credit that any interruptions of the Bank's conduct of business caused by an Act of God, riot, civil commotion, insurrection, war or other cause beyond the Bank's control, or by any strike or lockout, will automatically extend the expiration date hereof, as well as future expiration dates, by the period of the interruption. This Irrevocable Letter of Credit is subject to and governed by the laws of the State of Florida and the 2007 Revision of the Uniform Customs and Practice for Documentary Credits of the International Chamber of Commerce (Publication 600) and, in the event of any conflict, the laws of the State of Florida shall control. Should you have occasion to communicate with us regarding this Irrevocable Letter of Credit, kindly direct your communication to the attention of our Letter of Credit Department, making specific reference to our Irrevocable Letter of Credit No.______________________. If any legal proceedings are initiated with respect to payment of this Irrevocable Letter of Credit, it is agreed that such proceedings shall be subject to the courts and laws of the State of Florida. (The name and title of the executing bank officer must be typed below the officer's signature.) __________________________________________________Bank __________________________________________________Authorized Signature __________________________________________________Title __________________________________________________Address __________________________________________________Phone Number FORM DFS-F2-SI-6 (8/2009) Rule 69L-5.218, F.A.C. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com