Department of Labor and Industries Self-Insured Section PO Box 44891 Olympia WA 98504-4891 Non-USPS delivery: 7273 Linderson Way SW Tumwater WA 98501 IRREVOCABLE STANDBY LETTER OF CREDIT Letter of Credit No. Name of Bank Address of Bank Date of Expiration Effective Date Applicant (Employer's Name) Amount of Letter of Credit Place of Expiration Beneficiary: State of Washington, Department of Labor and Industries We hereby issue our irrevocable standby letter of credit (hereafter referred to as 'letter of credit') in favor of the state of Washington, Department of Labor and Industries, on behalf of ______________________________________________ (applicant) ____________________________________________________________________________________________________ This credit is available with _______________________________________________________________________________ by (issuing or confirming bank located in the State of Washington) negotiation of the beneficiary's draft drawn at sight on the issuing bank when accompanied by one of the three following statements, signed by the beneficiary: That the self-insurer has defaulted on its workers' compensation liabilities under Title 51 of the Revised Code of Washington (RCW). OR That the beneficiary has received written notice from the issuing bank that the letter of credit will not be renewed and that no replacement surety has been provided. OR That the beneficiary has determined that the existing security is deemed to be inadequate; that additional or replacement security must be provided by the self-insurer and that neither has been provided, notwithstanding written notice to the selfinsurer. This letter of credit is freely negotiable at any bank. Name of issuing bank drafts were drawn under Letter of credit number Dated (Issuing Bank's Name) Reimbursement instructions (or N/A) for the authorized negotiating bank is to obtain reimbursement The purpose of this letter of credit is to create a primary obligation of the part of this issuing bank. Also any confirming bank to the Department of Labor and Industries relating to the self This is in accordance with Title 51 RCW regardless of date of injury or occurrence. Except as stated herein, this letter of credit is not subject to any condition or qualification and is the issuing and any confirming bank's individual obligation which is in no way contingent upon reimbursement. This letter of credit will be automatically extended without amendment for one year from the expiration date shown above, or any future expiration date, unless at least 60 days prior to expiration, we notify the beneficiary by registered mail that we elect not to F207-112-000 assignment of account agreement 05-2008 American LegalNet, Inc. www.FormsWorkflow.com extend this letter of credit for such additional period. Such notice will be addressed to Program Manager for Self-Insurance, Department of Labor and Industries, PO Box 44891, Olympia WA 98504-4891. Name of Self-Insurer Letter of Credit Number Article 36 of the Uniform Customs and Practice for Documentary Credits does not apply to this letter of credit. If the issuing bank or any confirming bank is closed at the time of the expiration of this letter of credit for any reason that would prevent the delivery of a demand notice during its normal hours of operation, this letter of credit will be automatically extended for a period of 30 days commencing on the next day of operation. All bank charges for this letter of credit are for the account of the applicant. Any amendment to this letter of credit must be on the attached form (F207-112-111) Except so far as otherwise expressly stated, this letter of credit is subject to the Uniform Customs and Practice for Documentary Credits (2007revision), International Chamber of Commerce Publication #600, and to the laws of the state of Washington. In the event of a conflict between these authorities, the laws of the state of Washington will control. We hereby engage with drawers, endorsers, and/or bona fide holders that drafts drawn under and negotiated in strict conformity with the terms of this credit will be duly honored on presentation to us. The funds provided by this letter of credit are not construed to be an asset of the self-insurer. If any legal proceedings are initiated with respect to this letter of credit, it is agreed that such proceedings shall be subject to the courts and laws of the state of Washington. _____________________________________________________________________ is requested to add its confirmation to this letter of credit (name of confirming bank or N/A) Issuing Bank Name Title Signature Date _______________________________________________________________________ hereby undertakes to honor any drafts presented to it (name of confirming bank or N/A) when drawn under and in strict conformity with the terms of this credit. Confirming Bank Name Title Signature Date Accepted by State of Washington Department of Labor and Industries Date Program Manager for Self Insurance F207-112-000 irrevocable standby letter of credit 05-2008 American LegalNet, Inc. www.FormsWorkflow.com