DWC224 Texas Department of Insurance Division of Workers' Compensation Self-Insurance Regulation · MS 60 7551 Metro Center Drive, Suite 100 · Austin, Texas 78744-1645 (512) 804-4775 · (512) 804-4776 fax · www.tdi.texas.gov DOCUMENTARY IRREVOCABLE STANDBY LETTER OF CREDIT ("CONFIRMATION") Confirming Bank Confirmation Number (Name, Address, Contact, & Telephone No.) Effective Date Issuing Bank (Name, Address, Contact & Telephone No.) Beneficiary Texas Department of Insurance Division of Workers' Compensation Self-Insurance Regulation 7551 Metro Center Dr., Ste 100, MS-60 Austin, Texas 78744-1609 Amount (U.S. Dollars) (Written & Number) Reference Number of the Issuing Bank Applicant Name Please check the terms carefully. In the event that you do not agree with the terms and conditions, or if you are unable to comply with any of the terms and conditions, please arrange an amendment of the LOC through your contracting party (the applicant for the LOC). Letter of Credit Confirmation: We have been informed by the aforementioned issuing bank that the above-mentioned Documentary Irrevocable Standby Letter of Credit "(LOC)" has been issued in your favor. As requested by the issuing bank we hereby confirm the above-mentioned LOC. We undertake that all drafts under and in compliance with the terms of the LOC will be honored. Name of Confirming Bank Typed Signature Name & Title Authorized Signature Date DWC224 Rev. 01/07 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com