Form A-4 Agreement Of Assumption And Guarantee Of Workers Compensation Liabilities {A-4}

State of California Department of Industrial Relations OFFICE OF SELF-INSURANCE PLANS Certificate Number: In the Matter of the Certificate of GUARANTY OF WORKERS' COMPENSATION LIABILITIES Employer, (hereinafter called the Undersigned or Guarantor), has good and sufficient reason WHEREAS, for executing this Guaranty of Workers' Compensation Liabilities ("Agreement"); and (hereinafter called Self-Insurer), is, or has made WHEREAS, application to be, a self-insurer pursuant to Sections 3700 through 3705 inclusive of the Labor Code of California; NOW, THEREFORE, It is understood and agreed that: 1. In consideration of the Director of Industrial Relations of the State of California issuing a Certificate of Consent to Self-Insure to said Self-Insurer, the Undersigned agrees to guarantee to pay, or otherwise discharge promptly, all the liabilities and obligations which said Self-Insurer may incur as a self-insurer of its California workers' compensation liabilities (the "Obligations"). 2. This Agreement shall cover and extend to all potential liability for workers' compensation benefits as required by law of said Self-Insurer; as a self-insurer of its California workers' compensation liabilities arising under Self-Insurer's Certificate of Consent to Self-Insure regardless of whether those liabilities arose before or after execution of this Agreement. 3. This Agreement shall not cover or extend to any workers' compensation liabilities of said Self-Insurer which are expressly insured by a carrier duly authorized to write California workers' compensation insurance. 4. This Agreement shall remain in full force and effect unless properly and timely terminated in the manner hereinafter provided. 5. This Agreement may be terminated only upon the Undersigned's receipt of the express and mutual written consent of the Director of the Department of Industrial Relations ("DIR") and the Self-Insurers' Security Fund ("SISF"). In this event, and only in this event, the liability of the Undersigned, shall, upon receipt of such express written consent, cease and determine, except as to such liability of the Self-Insurer on account of any injury suffered by any of its employees prior to receipt of such express written consent; it being expressly understood and agreed that the Undersigned shall be liable for default of said Self-Insurer in fully discharging all existing and potential liability of said Self-Insurer as a self-insurer as of the date of said termination. American LegalNet, Inc. www.FormsWorkFlow.com Form A-4 (1-2016) Page 1 of 4 6. A change in the proprietorship or the sale of said Self-Insurer does not terminate this Agreement. 7. In the event said Self-Insurer shall fail to pay compensation, as compensation is defined in Section 3207, Labor Code of California, when due, the Undersigned will pay the same, and the payment may be enforced against the Undersigned to the same extent as if said payment was the liability of it. 8. The Undersigned is held and firmly bound for the payment of all legal costs incurred by the State of California in any actions taken to enforce this Agreement. 9. If the Undersigned has not filed with the California Secretary of State to the extent required to entitle it to transact intrastate business in California and/or if the Undersigned is a foreign entity (an entity organized and existing under the laws of a country outside the United States of America) it hereby agrees to become subject to the jurisdiction of the Department of Industrial Relations, the Division of Workers' Compensation, all other administrative agencies, and become controlled by California law including all regulations promulgated by the Director of Industrial Relations for the administration of selfinsurance for the purpose of enforcing the liabilities and obligations, and the resolution of any dispute arising from this Agreement. 10. If the Undersigned has not filed with the California Secretary of State to the extent required to entitle it to transact intrastate business in California it hereby agrees that service of process may be effected on the Undersigned by sending notice to by registered airmail, return-receipt requested. Pursuant to California Code of Civil Procedure Section 415.40, service of notice by this form of mail will be deemed complete on the tenth day after such mailing. 11. Continuing Guaranty. This is a continuing guaranty of the Obligations and is a guaranty of payment and performance of the Obligations and not of collection only. 12. Nature of Guaranty. The liability of Guarantor hereunder is independent of the obligations of Self-Insurer and a separate action or separate actions may be brought and prosecuted against Guarantor whether or not any action is brought or prosecuted against Self-Insurer or any other person, including any other guarantor of the Obligations, or whether Self-Insurer or any other person is joined in any such action or actions. The liability of Guarantor hereunder is independent of and not in consideration of or contingent upon the liability of any other person under this or any similar instrument and the release of, or cancellation by, any signer of this or a similar instrument shall not act to release or otherwise affect the liability of Guarantor hereunder. Guarantor waives the benefit of any statute of limitations affecting its liability hereunder or the enforcement thereof to the fullest extent permitted by law. 13. Waivers. Guarantor waives the right to require DIR or SISF to proceed against or exhaust any security held from Self-Insurer or any other person, or to pursue any other remedy in DIR's or SISF's power whatsoever and Guarantor waives the right to have the property of Self-Insurer first applied to the discharge of the Obligations. DIR or SISF may at its election exercise any right or remedy it may have against Self-Insurer or any security now or hereafter held by DIR or SISF, including, without limitation, the right to foreclose upon any such security by judicial or nonjudicial sale, without affecting or impairing in any way the liability of Guarantor hereunder, except to the extent the Obligations have been paid. Guarantor understands that the exercise by DIR or SISF of certain rights and remedies (including without limitation, non-judicial foreclosure against any real property security for the Obligations) may affect or eliminate Guarantor's right of subrogation, contribution or indemnification against Self-Insurer and that Guarant