STATE OF OREGON DEPARTMENT OF CONSUMER AND BUSINESS SERVICES Workers' Compensation Division 350 Winter Street NE P.O. Box 14480 Salem, OR 97309-0405 SURETY BOND KNOW ALL BY THESE PRESENTS, THAT WE, Bond number: with headquarters in the CITY OF as Principal and an Corporation authorized to transact surety business in Oregon, as "Surety," hereby jointly and severally bind ourselves, our respective heirs, executors, administrators, successors and assigns firmly by these presents unto the State of Oregon, as Obligee, for the use and benefit of all subject workers of the Principal, including subject workers of entitites approved by the department for inclusion in and included in the Principal's self-insurance certification, and persons who may be entitled to compensation under the Workers' Compensation Law of the State of Oregon, and to the Department of Consumer and Business Services, Workers' Compensation Division, of the State of Oregon for any assessments, contributions or other obligations due from the Principal to the Department of Consumer and Business Services, Workers' Compensation Division, in the penal sum of: Dollars ($ firmly by these presents. Under this bond any failure, by any entity approved by the department for inclusion in and included in the Principal's self-insurance certification, to pay compensation or to pay any assessments, contributions or other obligations shall be considered a failure to pay by the Principal. THE CONDITION OF THE (FOREGOING) OBLIGATION OF THIS BOND IS SUCH that if the Principal which is about to make application to become a certified self-insured employer or is a certified self-insured employer and desires to continue with self-insured status to carry its own risk, pays or causes to be paid: (a) all compensation for compensable injuries that may become due to subject workers and their beneficiaries of the Principal, including subject workers and their beneficiaries of all entities approved by the department and included in the Principal's self-insured certification; and (b) all assessments, contributions, and other obligations imposed on the Principal and the included approved entities and their subject workers that may become due from the Principal to the Department of Consumer and Business Services, Workers' Compensation Division under the Oregon Workers' Compensation Law, then this obligation shall be void; otherwise to remain in full force and effect. In the event the Principal fails to pay compensation that becomes due to any subject worker or beneficiary, or any assessments, contributions or other obligations that become due to the Department of Consumer and Business Services, Workers' Compensation Division under law, then the Surety will be obligated to pay the compensation, assessments, contributions, and other obligations. The liability of the , ), lawful money of the United States, assigns jointly and severally, 440-824 (1/10/DCBS/WCD/WEB) Continued American LegalNet, Inc. www.FormsWorkFlow.com SURETY BOND -- continued Surety shall not be affected by the Principal's failure to sign this bond. Nonpayment of the bond premium will not invalidate this bond nor shall the State of Oregon or the Department of Consumer and Business Services, Workers' Compensation Division of the State of Oregon be obligated for the payment of any premiums. IT IS FURTHER UNDERSTOOD AND AGREED that the following conditions shall also apply to this surety bond: 1. The Surety undertakes and agrees that the obligation of this bond shall cover and extend to all past, present, existing, and potential liability of said Principal, as a certified self-insured employer, including the Principal's liability and obligations for all entities approved by the department for inclusion in the Principal's self-insured certification, to the extent of the penal sum herein named, without regard to specific injuries, date or dates of injuries, happenings, or events. It is provided, however, that this undertaking, and the obligation of this bond, shall apply only to worker's claims for compensation and to the department's claims for assessments, contributions or other obligations arising under the Workers' Compensation Law, that result from or arise out of an occurrence that takes place on or after: through the date of termination of this surety bond or cancellation or revocation of the Principal's self-insurance certification. For the purpose of this paragraph, an occurrence is an event, circumstance, or exposure to conditions of any character that results in a compensable claim of any sort under the Workers' Compensation Law or which gives rise to an obligation to satisfy any assessments, contributions, or obligations under the Workers' Compensation Law. 2. In the event the Principal fails to pay compensation that becomes due to any subject worker or beneficiary covered by the Principal's self-insurance certification within ten (10) days after the same becomes or become due, or any assessments, contributions or other obligations that become due to the Department of Consumer and Business Services, Workers' Compensation Division under law, then the Surety will be obligated to pay the compensation, assessments, contributions and other obligations. The Surety shall forthwith pay to the extent of its liability under this bond, the Principal's liabilities and obligations as directed by the Department of Consumer and Business Services, Workers' Compensation Division, including reimbursement of payments the department has made or makes to parties entitled thereto, upon the order of the Department of Consumer and Business Services, Workers' Compensation Division. 3. If the Principal shall suspend payment or shall become insolvent or a receiver shall be appointed for its business, the undersigned Surety will be obligated to pay the compensation, assessments, contributions and other obligations, to the extent of its liability under this bond, before the expiration of ten (10) days after the same becomes due, as directed by the Department of Consumer and Business Services, Workers' Compensation Division, including reimbursement of payments the department has made or makes to parties entitled thereto upon the order of the Department of Consumer and Business Services, Workers' Compensation Division, without regard to any proceedings for liquidation of the Principal. 4. The undersigned are also held and firmly bound for the payment of all legal costs and expenses, including reasonable att