Illinois Workers' Compensation Commission Parent Guaranty Agreement In Connection With Self-Insurance Privilege Form Page 5

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CORPORATE ATTESTATION

FOR SECRETARY OR ASSISTANT SECRETARY

Complete and attach this form to the Corporate Certificate in Connection with Guaranty of Self-Insurance Obligations.

State of

______________

)

County of ______________

)

On ___________________ , before me personally appeared ______________________________________________ ,

Date

Name of Secretary/Assistant Secretary

❑

the

Secretary or

Assistant Secretary of ______________________________________________________ ,

Check one

Name of Guarantor

who is personally known to me and who, being duly sworn, deposes and says that he or she executed the attached

Certificate; that the seal affixed to the Certificate is the above-named corporation’s true and proper corporate seal; that all

of the statements contained in the Certificate are true and correct; and that he or she executed the Certificate and affixed

the corporate seal thereto by virtue of authority duly conferred by the above-named corporation.

IN WITNESS THEREOF, I have hereunto set my hand and affixed my official seal, the date stated above.

__________________________________________________

Notary Public

My commission expires: _____________________________

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.

IC90B 5/09 IWCC Office of Self-Insurance Administration 4500 S. Sixth St. Frontage Rd. Springfield, IL 62703 217/785-7084