Free 82A-AI.qxd - Missouri

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

DIVISION OF WORKERS COMPENSATION
P.O. Box 58, Jefferson City, MO 65102-0058

Guaranty To Satisfy Compensation Claims Under Workers Compensation Law of Missouri

IN THE MATTER OF _______________________________________________________________________________________________, to guarantee prompt and full payment of any and all of its liabilities under or by virtue of the Workers' Compensation Law of Missouri. KNOW ALL MEN BY THESE PRESENTS: That the Undersigned, _________________________________________________________________________ a corporation organized and existing under and by virtue of the Laws of the State of _______________________________ ________________________________, being financially interested in the _____________________________________ _______________________________________, a corporation organized and existing under and by virtue of the Laws of ____________________________________________________, and desiring to enable said _______________________ ____________________________________________________to comply with the Laws of the State of Missouri, known as "Workers' Compensation Law", in consideration of the granting of the right of self-insurance or to continue as a self-insurer if authority has been granted under said Law to _________________________________________________ ________________________________________________, by the State of Missouri, Division of Workers' Compensation, does hereby agree and guarantee on behalf of said __________________________________________________________ ______________________________________, that any and all liabilities against said ____________________________ _____________________________________________, under or by virtue of said "Workers' Compensation Law" will be promptly and fully paid. This guarantee shall enure to the benefit of and may be enforced by the State of Missouri and any and all employees or dependents of said _________________________________________________________________ _________________________________________ having a claim or which may have a claim against it under said Law or

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by the State of Missouri, Division of Workers' Compensation, as established by said Law, for the benefit of any such employee or employees or their dependents of said ________________________________________________________ ______________________________________________,

IN WITNESS WHEREOF said _________________________________________________________________ has caused this instrument to be signed by its president and its corporate seal to be hereunto affixed and attested by its secretary, this __________________________ day of ___________________________, __________.

SIGNED: ___________________________________________ Corporation

by: _________________________________________________ President

(Seal) Attest:

__________________________________ Secretary STATE OF _______________________ ( ( COUNTY OF _____________________ ( On this _____________________________ day of _____________________, _________, before me, personally came ______________________________________, to me known who, being duly sworn, did depose and say that he/she resides in _____________________________________________________, that he/she is _________________________ ________________________________________________ of the ____________________________________________ the corporation described in and which executed the foregoing instrument; that he/she knows the seal of the said corporation; that he/she knows the seal affixed to said instrument is such corporate seal, that it was affixed by the order of the Board of Directors of said corporation and that he/she signed his/her name thereto by like order.

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WITNESS my hand and seal the day and year aforesaid. ______________________________________ Notary Public My Commission expires: ________________________

(NOTARY SEAL)

This instrument must be accompanied by a certified copy of the resolution duly adopted by the Board of Directors (or stockholders) authorizing and directing the execution of this agreement.

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