STATE OF OREGON DEPARTMENT OF CONSUMER & BUSINESS SERVICES Workers’ Compensation Division 350 Winter Street NE P.O. Box 14480 Salem, OR 97309-0405 SURETY RIDER To be attached to and form a part of bond number executed by , as Principal and by , as Surety, in favor of , and effective on the day of 20 . In consideration of the mutual agreements herein contained, the Principal and the Surety hereby consent to changing the amount of bond liability from $ to $ For the purpose of the named Principal remaining self-insured in the State of Oregon, the Surety undertakes and agrees that the obligation of this endorsement and the above-referenced surety 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, happenings, or events. Nothing herein contained shall vary, alter, or extend any provision or condition of this bond except as herein expressly stated. This rider is effective on the Signed and sealed this day of day of 20 20 Surety Principal Signature Signature Name and title Name and title Accepted, but not as a substitute surety bond, this Department of Consumer & Business Services Workers’ Compensation Division of the State of Oregon, Obligee day of 20 Signature Name and title 440-1810 (1/05/DCBS/WCD/WEB) Continued American LegalNet, Inc. www.USCourtForms.com SURETY RIDER — continued OR Accepted, as a substitute surety bond, this Department of Consumer & Business Services Workers’ Compensation Division of the State of Oregon, Obligee day of 20 Signature Name and title OR Accepted, as a substitute surety bond for all previous bonds, this Department of Consumer & Business Services Workers’ Compensation Division fo the State of Oregon, Obligee day of 20 Signature Name and title 440-1810 (1/05/DCBS/WCD/WEB) American LegalNet, Inc. www.USCourtForms.com