Illinois Workers' Compensation Commission Parent Guaranty Agreement In Connection With Self-Insurance Privilege Form Page 2

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V. Settlements and Defense of Claims: Except as provided below, the Guarantor shall not be liable for any settlements of claims

against any Employer alleging liability under the Acts or for the related costs of defense, without the written agreement of the

Guarantor or said Employer to such settlements. However, in the event that the Board determines that any Employer is an insolvent

self-insurer, the Board is authorized to administer and defend all claims against said Employer under the Acts as a private self-insurer

and pay said claims and the related administrative and defense costs on behalf of said Employer and the Guarantor without the consent

of said Employer, the Employer’s successor or the Guarantor.

VI. Termination of Guaranty: The Guarantor may terminate this Agreement at any time by delivering written notice of termination

to the Chairman, with a copy directed to the Board. Such notice shall become effective no sooner than one hundred eighty (180) days

after the date of its receipt by the Chairman, unless the Chairman shall give written consent to an earlier effective date.

Notwithstanding the foregoing, termination of the Agreement shall not affect the Guarantor’s obligations hereunder with respect to

any injury or exposure occurring prior to the effective date of termination.

VII. Reaffirmation of the Guaranty: In his or her sole discretion, the Chairman may, from time to time, require the Guarantor to

reaffirm its obligations under this Agreement by re-executing the form of this Agreement as it may subsequently be revised by the

Commission. The Guarantor shall comply with the Chairman’s demand for such a reaffirmation within fifteen (15) days of its receipt.

Notwithstanding the foregoing, the Guarantor shall remain liable under the terms of this Agreement even in the absence of any such

reaffirmation.

VIII. Choice of Venue; Consent to Jurisdiction; Waiver of Personal Service: Any action, suit or proceeding commenced by any

person in connection with this Agreement shall be brought in a local or state court located in either Cook County or Sangamon

County, Illinois. The Guarantor hereby consents to the jurisdiction of any such court in any action suit or proceeding commenced in

connection with this agreement and waives any objection to venue in connection therewith. The Guarantor hereby waives personal

service of process or papers to be served in connection with the foregoing and agrees that such service may be made by overnight

courier or by registered or certified mail, return receipt requested. If mailed, such process or papers shall be deemed received five (5)

business days thereafter.

The section headings in this Agreement are for reference only and shall not effect the meaning or interpretation of the Agreement.

In the event any provision of this Agreement is deemed to be in violation of law, such provision shall not be deemed to impair the

validity of any other provision hereof.

SIGNED AND SEALED ON _________________________________________________ , which shall also be the date on which

the Agreement shall be effective.

GUARANTOR CORPORATE SEAL

_________________________________________________________

Signature of Guarantor’s President/Vice-President/General Partner

Date

_________________________________________________________

Name and Title of President/ Vice-President/ General Partner

This Agreement is approved by the

________________________________________________________

Illinois Workers’ Compensation Commission.

Chairman

Date

Disclosure of this information is voluntary under the Illinois Workers’ Compensation Act, but failure to complete the form may prevent the IWCC from processing it.

IC90 5/09 IWCC Office of Self-Insurance Administration 4500 S. Sixth St. Frontage Rd. Springfield, IL 62703 217/785-7084