COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Department of Labor and Industries Self-Insurance Section PO Box 44891 Olympia WA 98504-4891 Express Mail: 7273 Linderson Way SW Tumwater WA 98501 Index No. : Plaintiff(s) -against: SELF-INSURER'S Calendar No. PENSION BOND JUDICIAL SUBPOENA : BOND NO: : KNOW ALL PERSONS BY THESE PRESENTS, that_______________________________ _________________________________________, as Principal, having its principal office at : _____________________________________________________________________________, and_________________________________________________________________________, a Defendant(s) : . .company .authorized .to. transact . surety .business . in. the. . . . . .of. Washington, having its principal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . state . . office at _____________________________________________, as Surety are held and firmly bound unto the STATE OF WASHINGTON, DEPARTMENT OF LABOR AND INDUSTRIES, in the penal sum of _______________________________________________ DOLLARS THE PEOPLE OF THE STATE OF NEW which the Principal and Surety bind themselves, their ($________________), the payment of YORK heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these TO presents. The condition of the above obligation is such that the said Principal has elected to reimburse the said Department, under the provisions of RCW 51.44.070, for the payments to be made from the GREETINGS: Pension Reserve Fund for claim number ____________________________________________, claimant___________________________________________. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court NOW THEREFORE, it is understood and agreed that: located at County of in room the Principal shall reimburseof Department for all at , on the day the , 20 , paymentso'clock in the noon, and 1. If by the Department from theat any recessed or Pension Reserveto testify and claimant accordingwitnessterms and provisionspartRCW 51.44.070, adjourned date, Fund to the give evidence as a to the in this action on the of of the then this obligation shall be null and void; otherwise it remains in full force and effect. The Surety agrees that it may not assign or transfer its rights, remedies, obligations or causes of action under this bond without written approval of the Department of Labor and Industries. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf associated with this obligation shall be reviewed annually. Any damages sustained as a 2. The pension reserve this subpoena was issued for a maximum penalty of $50 and all change resultthe your failureof this bond will extend to the entire pension obligation and be issued on the to of penal sum to comply. Department's pension bond rider, which will be attached to this bond. Witness, Honorable , one of the Justices of the 3. This bond is subject to acceptance by the Self-Insurance Program Manager. The original will Court in County, day of , 20 be filed in the Self-Insurance Section of the Department of Labor and Industries. 4. This bond is continuous in form and shall remain in full force and effect unless terminated in (Attorney must sign above and type name below) the manner hereinafter provided. 5. This bond may not be terminated by either the Principal or the Surety unless the Principal Attorney(s) for shall first provide a cash deposit or substitute bond in accordance with the terms of RCW 51.44.070. 6. The Principal and the Surety are held and firmly bound for the payment of all legal costs, including reasonable attorney's fees incurred in any or all actions or proceedings taken to enforce Office and P.O. Address payment under this bond, or payment of any award or judgment rendered against the Surety, on account of the execution of this bond. F207-065-000 (w) self-insurer's pension bond 10-01 Telephone 7. The effective date of this bond is ____________________________. No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: page 1 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Name of Claimant Claim Number Index No. Calendar No. Bond Number : : Plaintiff(s) JUDICIAL SUBPOENA -against: 8. If the Principal shall cease reimbursing the Department for payments made by the Department to the beneficiary or beneficiaries, and demand is made upon the Surety, the Surety shall pay any : delinquent reimbursements owed by the Principal. The Surety shall then have the option to: : A. Pay the Department a sum of money equal to the cash value of the remaining pension reserve as calculated annually by the Department, or, Defendant(s) : ...................................................... B. Continue to pay the quarterly reimbursement owed by the Principal to the Department of Labor and Industries until such obligation ceases or until the Surety exercises the option of paying the cash value of the pension reserve as calculated by the Department. Quarterly reimbursements paid YORK THE PEOPLE OF THE STATE OF NEW by the Surety shall not be limited to the penal sum of this bond nor shall they be deducted from the penal sum of this bond. TO Principal GREETINGS: Name Title Date WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable Court Signature at the located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Surety Name Date Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Title the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Signature Witness, Honorable Court in County, , one of the Justices of the day of , 20 Accepted by the State of Washington Department of Labor and Industries Date Self-Insurance Program Manager (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address F207-065-000 (w) self-insurer's pension bond 10-01 page 2 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: