1. a) Each pool must certify its compliance with Section 107a.08(a) and (b) of the Illinois Insurance Code [215 ILCS 5/107a.08(a) and (b)] to the Director by having each pool trustee file the prescribed certification form below by March 1 of each year to indicate that the pool members possess homogeneous risk characteristics. The Director may require certifications more frequently than on an annual basis if deemed necessary.

2. b) The Trustees shall each certify that:

   1. 1) The trustee has requested the administrator to provide all relevant information regarding the homogeneous risk characteristics of the members.
   2. 2) The trustee has reviewed all relevant information regarding the homogeneous risk characteristics of the members as well as the guidelines relating to homogeneity in Section 107a.08 of the Code, in addition to those defined in Section 575.110 of this Part.
   3. 3) Based on the trustee's knowledge and review, the trustee shall verify that the certification is true, complete and not misleading.
   4. 4) Based on the trustee's knowledge, the certification presents in all material respects that the members exhibit homogeneous risk characteristics under the membership scope adopted by the pool.
   5. 5) The trustee understands his or her legal responsibility to ensure under Article V¾ of the Code that the members exhibit homogeneous risk characteristics.
   6. c) The certification must be accompanied by a list of members as of the end of the previous year that includes for each member a description of business activities, list of NCCI class codes used to classify the member's payroll, gross annual payroll by class code, number of employees, and identification of new members added during the previous year.

   7. d) For the initial certification, March 1, 2010, an affidavit describing the membership scope of the pool consistent with the standards prescribed in this Part must accompany the certification. Supporting documentation must be submitted that demonstrates that the membership scope possesses homogeneous risk characteristics.

      STATE OF ILLINOIS

      CERTIFICATION OF HOMOGENEITY

      I,	(Name of Trustee)	, a Trustee or Director of	(Name of Workers' Compensation
      	Pool)	present this Certification to the Director of Insurance of the State of Illinois
      for the period of January 1 through December 31,		. I certify that:

      (1) I have requested the administrator provide all relevant information regarding the homogeneous risk characteristics of the members.

      (2) I have reviewed all relevant information regarding the homogeneous risk characteristics of the members, as well as the guidelines relating to homogeneity in Section 107a.08 of the Illinois Insurance Code [215 ILCS 5/107a.08] and 50 Ill. Adm. Code 575.

      (3) Based on my knowledge and review of (2) above, I verify that the certification is true, complete and not misleading.

      (4) I understand the legal responsibility I have in respect to ensuring that the members exhibit homogeneous risk characteristics.

      (5) I certify that the members do exhibit or do not exhibit (Please check one) homogeneous risk characteristics relative to the membership scope adopted by the pool.

      Signature		Title
      Printed Name		Date
      Street Address
      City
      State
      ZIP Code

      Notary Public

      (Seal)

      Date

Certification by the Trustees