Free Adobe PDF - Illinois

ILLINOIS WORKERS' COMPENSATION COMMISSION SELF-INSURER'S SURETY BOND SELF-ADMINISTERED CLAIMS ENDORSEMENT

Bond No.: Executed by and by

________________________ __________________________________________________________ , as Principal (Employer) __________________________________________________________ , as Surety.

Whereas, the Principal on the above Self-Insurers' Surety Bond has applied to the Illinois Workers' Compensation Commission to self-administer all claims made by Principal's employees while the Principal is a private self-insurer. Now, therefore, as a condition of granting the Principal permission to self-administer said claims, the Surety and Principal hereon agree that the obligation under this Surety Bond is extended to include payment of all related costs of defense, including the fees and costs of administrators appointed by the Surety or Illinois Self-Insurers' Advisory Board for the administration and defense of claims by Principal's employees as a result of injuries or exposures covered by the Surety Bond.

_____________________________________________
Signature of Principal's representative Date

____________________________________________
Signature of Surety's representative 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. IC55 5/09 Illinois Workers' Compensation Commission Office of Self-Insurance Administration 4500 S. Sixth Street Springfield, IL 62703 217/785-7084