COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. MEMORANDUM OF UNDERSTANDING : Calendar No. This is a Memorandum of Understanding between: Plaintiff(s) : JUDICIAL SUBPOENA -against: (Employer), and the Maryland Workers’ Compensation Commission (Commission). The Employer has applied for the privilege of self- insuring its obligations under the Maryland : Workers’ Compensation Law Section 9- 405 (Labor and Employment Article) and the Commission has approved the application contingent upon : Employer posting security in the the amount of $ . The Employer wishes to meet this security requirement by posting an Irrevocable Letter of Credit (Letter of Credit) :issued or confirmed by: Defendant(s) ...................................................... , which is a Maryland chartered financial instit ution or federally chartered financial institution with a Maryland office. The Commission and the Employer agree to the following: THE PEOPLE OF THE STATE OF NEW YORK 1. TO 2. The Letter of Credit is being furnished to the Commission in lieu of a surety bond, book entry or other security to meet one of the conditions established by the Commission for the Employer to self- insure. Expiration or cancellation of the Letter of Credit is effective sixty (60) days after the GREETINGS: Commission has received written notice by registered mail of the cancellation. WE COMMAND YOU, that all that the Letter of Credit islaid aside, you and each of you attend before 3. If the Commission is notified business and excuses being being canceled or will not be , the Honorable at the Court renewed and a new letter of credit or other form of security deposit acceptable to the located at County of Commission is not filed with the Commission, the Commission may, at its discretion, in room , on the day of , 20 , at o'clock in the noon, and at any recessed draw on the Letter of Credit. or adjourned date, to testify and give evidence as a witness in this action on the part of the 4. The Commission, may, at any time, draw on the Letter of Credit if needed to pay any workers’ compensation claim and claims administration expense which are the Your failure to complySelf-Insurer. responsibility of the with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your proceeds comply.on the Letter of Credit shall be deposited with the State Treasurer and 5. All failure to drawn a Trust shall be established to pay the obligations of the Self-Insurer under Maryland Witness, Compensation Law. , one of the Justices of the Workers Honorable Court in 6. County, day of , 20 If the Letter of Credit Issuer is a Financial Institution whose financial standing according to Weiss Ratings Inc. falls below a B- , the Self- Insurer herein must replace the Financial Institution with another company with an B- or above rating within 60and typeof below) (Attorney must sign above days name notification by the Commission. If the Self-Insurer herein has discontinued making payments and responsibility for the payment of claims has been transferred to a Commission designated third party and the Financial Institution’s Weiss Ratings falls Attorney(s) for below B-, the Commission at its sole discretion may demand that the full amount of the Letter of Credit, shall be placed in a Maryland depository in the name of the Maryland Workers’ Compensation Commission, for the use and benefit of all employees of the Self-Insurer herein and persons who may be entitled to compensation, medical, surgical Office and P.O. Address and other services and funeral expenses under the Workers’ Compensation Law of the State of Maryland. The Commission will release all unspent Letter of Credit funds back to the Financial Institution after determination that all workers’ compensation liabilities Telephone No.: of the Self-Insurer herein while self- insured have been satisfied Facsimile No.: E-Mail Address: Mobile Tel. No.: WCC Form A-09 (703) Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 7. Index No. : Calendar The Letter of Credit and this Memorandum of Understanding shall No.governed by the be laws of Maryland and subject to the Uniform Customs & Practice for Documentary : JUDICIAL SUBPOENA Plaintiff(s) Credits, 1993 Revision, ICC Publication Number 500. Any action with respect to the -againstLetter of Credit shall be brought in Maryland and the Self- Insurer shall consent to the : court’s personal jurisdiction over the Employer. : 8. In the event that the employer’s self- insurance status is terminated, the Irrevocable Letter : of Credit is demanded and responsibility for payment of claims is transferred to a third party administrator by Order of the Commission, the employer shall immediately release Defendant(s) : . . . . . . . . all. workers’. compensation .files. and .reports. including indemnity and medical case records .. ....... ............ ... ... ..... ........ and files, related records on paid, incurred, case reserve and IBNR estimates and other reports required by the designated third party administrator. THE PEOPLE OF THE STATE OF NEW YORK 9. TO In this Memorandum of Understanding, “Employer” means the following entities, which have been approved to self- insure in Maryland (parent and subsidiaries): GREETINGS: WE COMMAND YOU, that all business and excuses being laid the name of the each of the attend (If required, please attach a page listing additional subsidiaries, including aside, you and par ent atyou top.) before , the Honorable at the Court 10. Understanding is effective on: County ofThis Memorandum of located at in room , on the day of , 20 , at o'clock in the noon, and at any recessed orSignature: adjourned date, to testify and give evidence as a witness in this action on the part of the Employer Your failure to comply Representative of Employer with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Title Date Court in Witness, Honorable County, , one of the Justices of the day of , 20 Signature: (Attorney must sign above and type name below) Representative of the Commission Title Attorney(s) for Date Office and P.O. Address Form A-08: Letter of Credit. This form should be filed concurrently with the Irrevocable Letter of Credit at the Maryland Workers’ Compensation Commission, Insurance Division, 10 E. Telephone No.: Baltimore Street, Baltimore, Md. 21202. The Letter of Credit will not be accepted without the Facsimile No.: accompanying Memorandum of Understanding. E-Mail Address: Mobile Tel. No.: WCC Form A-09 (703) Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com