Fill and Sign the Workers Compensation Surety Rider Oregon Form

STATE OF OREGON DEPARTMENT OF CONSUMER AND 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 (check one) penal sum Principal penal sum and Principal 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 any entity that is or has been approved by the department for inclusion in and included in a self-insurance certification in which the Principal has been included , 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    day of       20    Signed and sealed this    day of       20                Surety Principal Signature Signature             Name and title Name and title             Principal Principal Signature Signature             Name and title Name and title 440-1810 (1/17/DCBS/WCD/WEB) Page 1 of 2 SURETY RIDER — continued       Principal Signature       Name and title Accepted , but not as a substitute surety bond, this    day of       20    Department of Consumer & Business Services Workers’ Compensation Division of the State of Oregon, Obligee Signature       Name and title OR Accepted , as a substitute surety bond, this    day of       20    Department of Consumer & Business Services Workers’ Compensation Division of the State of Oregon, Obligee Signature       Name and title ORAccepted , as a substitute surety bond for all previous bonds, this    day of       20    Department of Consumer & Business Services Workers’ Compensation Division fo the State of Oregon, Obligee Signature       Name and title 440-1810 (1/17/DCBS/WCD/WEB) Page 2 of 2