Parent Guaranty Agreement In Connection W- Self-Insurance Privilege Amendatory Schedule Of Addl Employers {IC91}

ILLINOIS WORKERS' COMPENSATION COMMISSION PARENT GUARANTY AGREEMENT IN CONNECTION WITH SELF-INSURANCE PRIVILEGE AMENDATORY SCHEDULE OF ADDITIONAL EMPLOYERS Guarantor Name: Guarantor Address: _______________________________________________________________________________ _______________________________________________________________________________ Whereas, each of the employer(s) listed below in the first numbered paragraph ("Additional Employer(s)") has applied for 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"); Whereas, 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 Additional Employer(s) or the Guarantor has the right to elect or appoint, directly or indirectly, a majority of the directors, trustees or other governing body of each Additional Employer(s), or has the right to approve and disapprove, directly or indirectly, the persons appointed as a majority of the directors, trustees or other governing body of each Additional Employer(s); Whereas, the Guarantor has previously executed the Parent Guaranty Agreement in Connection with Self-Insurance Privilege ("Guaranty") to which this Amendatory Schedule is attached, which Guaranty remains in full force and effect; and Whereas, the Illinois Workers' Compensation Commission requires that the Guarantor also guarantee the self-insured obligations of each Additional Employer(s) as a condition of the qualification of the Additional Employer(s) as a private self-insurer(s) under the Acts. Now, therefore, in consideration of the qualification of each Additional Employer(s) as a private self-insurer(s) under the Acts, the Guarantor hereby agrees as follows: 1. Amendment of Guaranty: The Guaranty is hereby amended to include the Additional Employer(s) named below among the "Employers" identified as such under the terms of the Guaranty: NAME __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ ADDRESS ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 2. Scope of Guaranty: The Guaranty shall be effective in accordance with its terms and conditions for all of the obligations as a private self-insurer under the Acts of each Additional Employer(s) and each of the other entities identified as "Employers" under the terms of the Guaranty, whether those obligations were incurred prior to, on or after the date hereof. 3. Effect of Amendatory Schedule: Nothing herein contained shall vary, alter or extend any provision or condition of the Guaranty except as herein expressly stated. SIGNED AND SEALED ON ______________________________________ , which shall also be the date on which this Amendatory Schedule shall be effective. GUARANTOR CORPORATE SEAL _______________________________________________________ Signature of Guarantor's President/Vice-President/General Partner Date _______________________________________________________ Name 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. IC91 5/09 Illinois Workers' Compensation Commission Office of Self-Insurance Administration 4500 S. Sixth Street Springfield, IL 62703 217/785-7084 American LegalNet, Inc. www.FormsWorkFlow.com