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ILLINOIS WORKERS' COMPENSATION COMMISSION SELF-INSURER'S ESCROW AGREEMENT AMENDMENT

To be attached to and form a part of the Self-Insurer's Escrow Agreement

Trust No. Executed by and by in favor of:

_______________________________ ___________________________________________________________________ , as Employer, ___________________________________________________________________ , as Escrow Agent, Illinois Workers' Compensation Commission , as Obligee.

In consideration of the mutual agreements herein contained the Employer and Escrow Agent hereby agree to the following changes: Change Name From: __________________________________________________________________________ To: __________________________________________________________________________

Change Amount From: __________________________________ To: ___________________________________ Addition (A) and Deletion (D) of Employer

Nothing contained herein shall vary, alter, or extend any provision or condition of the Escrow Agreement except as expressly stated. EMPLOYER CORPORATE SEAL BANK CORPORATE SEAL

_____________________________________________
Signature of Employer's representative Date

__________________________________________
Signature of Escrow Agent's representative Date

_____________________________________________
Name and title

__________________________________________
Name and title

__________________________________________
Signature of Attestant Date

__________________________________________
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. IC63 5/09 Illinois Workers' Compensation Commission Office of Self-Insurance Administration 4500 S. Sixth Street Springfield, IL 62703 217/785-7084