Surety Rider {1810}

STATE OF OREGON DEPARTMENT OF CONSUMER & BUSINESS SERVICES Workers Compensation Division 350 Winter Street NE, Room 27 Salem, OR 97301-3879 SURETY RIDER To be attached to and form a part of Bond executed by , as Principal and by , as Surety, in favor of , and effective as of . In consideration of the mutual agreements herein contained, the Principal and the Surety hereby consent to changing the AMOUNT OF BOND LIABILITY 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 self-insurer, to the extent of the penal sum herein named, without regard to specific injuries, date or dates of 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 PRINCIPAL: By X Name and title ACCEPTED: Department of Consumer & Business Services SURETY: Workers Compensation Division Obligee By X By X Attorney-in-Fact Name and title 440-1810 (5/00/DCBS/WCD/WEB)