Free Adobe PDF - Illinois

ILLINOIS WORKERS' COMPENSATION COMMISSION SELF-INSURER'S SURETY BOND GENERAL PURPOSE RIDER

To be attached to and form a part of the Self-Insurer's Surety Bond Bond No.: Executed by: and by: in favor of: __________________________ ____________________________________________________________ , as Principal (Employer), ____________________________________________________________ , as Surety, Illinois Workers' Compensation Commission , as Obligee.

In consideration of the mutual agreements herein contained the Principal and Surety hereby agree to the following changes: Change Name From: _____________________________________________________________________________ To: _____________________________________________________________________________

Change Amount From: ____________________________________ To: ____________________________________

Addition (A) and Deletion (D) of Principal (Employer)

Nothing herein contained shall vary, alter, or extend any provision or condition of the Surety Bond except as expressly stated. PRINCIPAL (EMPLOYER) CORPORATE SEAL SURETY CORPORATE SEAL

___________________________________________
Signature of Principal's representative Date

___________________________________________
Signature of Attorney-In-Fact Date

___________________________________________
Name and title

___________________________________________
Name and title

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. IC53 5/09 Illinois Workers' Compensation Commission Office of Self-Insurance Administration 4500 S. Sixth Street Springfield, IL 62703 217/785-7084