REV 08/2018 SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION DIVISION OF LABOR AND MANAGEMENT 123 W. Missouri Ave. Pierre, South Dakota 57501 Tel: 605.773.3681 Fax: 605.773.4211 dlr.sd.gov ASSUMPTION OF SELF-INSURANCE OBLIGATIONS WHEREAS, (the Company), a corporation authorized to do business in the State of South Dakota, has filed an application with the State of South Dakota, Department of Labor and Regulation , for exemption beginning , from the requirement to insure its liability under the Workers' Compensation Law of South Dakota for compensation and medical benefits to injured employees. In said application the Company undertakes and agrees to pay as the same may become due, all legal liabilities and obligations, including but not limited to all claims for compensation benefits and medical expenses which may accrue against the Company under the Workers' Compensation Law of South Dakota and amendments thereto, arising out of injuries and diseases sustained by its employees and further agrees that it will comply with all of the provisions of the Workers' Compensation Law of the State of South Dakota and any amendments thereof, and the rules and regulations of the South Dakota Department of Labor and Regulation, with reference thereto; and WHEREAS, the Company as a controlled subsidiary of (the Guarantor), a corporation organized, existing, and authorized to do business by the laws of the State of . NOW, THEREFORE, in consideration of exemption and other good and valuable consideration, the Guarantor agrees and undertakes to absolutely and unconditionally pay and perform each and every undertaking assumed by the Company as a condition to being granted a certificate to self-insure, and further agrees that the obligations assumed by it hereunder are primary and not collateral to the obligations of the Company. IN TESTIMONY WHEREOF, the Guarantor has caused the presents to be executed on this day of , 20 . by Name of Guarantor Officer of Guarantor ATTEST: Signed, sealed and delivered in the presence of: AFFIX CORPORATE SEAL American LegalNet, Inc. www.FormsWorkFlow.com