Illinois Workers' Compensation Commission Parent Guaranty Agreement In Connection With Self-Insurance Privilege Form Page 4

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ILLINOIS WORKERS’ COMPENSATION COMMISSION

CORPORATE CERTIFICATE IN CONNECTION WITH GUARANTY OF SELF-INSURANCE OBLIGATIONS

Date:

______________________________________

Guarantor Name:

_____________________________________________________________________________________

Guarantor Address:

_____________________________________________________________________________________

The Illinois Workers’ Compensation Commission (“Commission”) granted the Employer(s) named on Exhibit A attached hereto

permission to self-insure under the laws of the State of Illinois known as the Workers’ Compensation Act and the Workers’

Occupational Diseases Act, both effective July 9, 1951, as amended, (hereinafter collectively called the “Acts”). Such permission

conditioned upon the requirement that the Guarantor hereby absolutely and unconditionally guarantee and promise to pay: (1) each

Employer’s obligations incurred under the Acts as the result of injuries or exposures occurring at any time while the Employer is a

qualified private self-insurer under the Acts and (2) the related administrative and defense costs.

Now, therefore, the undersigned does hereby certify that:

The Guarantor is a corporation duly organized and validly existing under the laws of the State of ________________________ .

Asst. Secretary

The undersigned is the duly elected and acting _____________________________________________ of the Guarantor, and

Secretary or Assistant Secretary

_____________________________________________ is the duly elected

Name of officer executing the Guaranty

President

and acting _____________________________________________ of the Guarantor. Attached is a true and correct

President or Vice-President

copy of the corporate minutes evidencing the election of _____________________________________________

Name of officer executing the Guaranty

President

as said _____________________________________________ .

President or Vice-President

Pursuant to the terms of the Guarantor’s by-laws, charter or other organizational documents, the Guarantor and the above-named

President or Vice-President have full power and authority to enter into, execute and deliver the required Guaranty and any

Amendatory Schedule(s) of Additional Employers thereto (copies of which are attached hereto) to the Illinois Workers’

Compensation Commission, and the Guaranty, as amended by any Amendatory Schedule(s) of Additional Employers, constitutes

the valid and binding obligation of the Guarantor in accordance with its terms.

The Guarantor, directly or indirectly, owns, controls or holds, with the power to vote, more than fifty percent (50%) of the

outstanding voting securities of each Employer.

GUARANTOR CORPORATE SEAL

_________________________________________________________

Signature of Secretary/Assistant Secretary

Date

_________________________________________________________

Name of Secretary/Assistant Secretary

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.

IC90A 5/09 IWCC Office of Self-Insurance Administration 4500 S. Sixth St. Frontage Rd. Springfield, IL 62703 217/785-7084