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ILLINOIS WORKERS' COMPENSATION COMMISSION SELF-INSURER'S SURETY BOND CANCELLATION AMENDMENT AND ACKNOWLEDGEMENT

Bond No.:

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Cancellation Effective Date: ________________________ Principal (Employer) Name: Address: Surety Name: Address: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Whereas, the Principal is continuing without interruption as a private self-insurer pursuant to permission granted by the Illinois Workers' Compensation Commission, and Whereas, the Principal has furnished a new surety bond or other financial security instrument acceptable to the Illinois Workers' Compensation Commission to guarantee the Principal's performance as a private self-insurer from and after the Cancellation Effective Date of the Surety Bond listed above, Now, therefore, the Surety Bond listed above is amended, and the Surety thereon hereby is released and discharged. The Surety Bond is cancelled on the Cancellation Effective Date listed above and the Surety's obligation thereon is void.

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Signature of Surety's representative Date

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Name and title

This cancellation and amendment is acknowledged by the Illinois Workers' Compensation Commission.
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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. IC56 5/09 Illinois Workers' Compensation Commission Office of Self-Insurance Administration 4500 S. Sixth Street Springfield, IL 62703 217/785-7084