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ILLINOIS WORKERS' COMPENSATION COMMISSION SELF-INSURER'S AGREEMENT TO POST LETTER OF CREDIT SCHEDULE OF SUPPLEMENT

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

Date:

__________________

Employer Name: ________________________________________________________________________________________________ Address: ________________________________________________________________________________________________ Issuing Bank Name: __________________________________________________________________ Address: __________________________________________________________________ Confirming Bank Name: __________________________________________________________________

LOC No.: Amount $:

________________ ________________

Confirmation No.: ___________

Address: ________________________________________________________________________________________________ Whereas, the Employer has previously entered into a Self-Insurers Agreement to Post Letter of Credit ("Agreement") to which this Schedule is attached; and Whereas, the Employer wishes to supplement one or more of the letter(s) of credit ("Letter of Credit") deposited with the Illinois Workers' Compensation Commission ("Commission") pursuant to the terms of the Agreement and/or pursuant to the terms of any other schedule(s) attached thereto. Now, therefore, as a condition of its continued qualification for the self-insurance privilege or for the use and benefit of its employees as a former self-insurer, the Employer is depositing with the Commission the irrevocable Letter of Credit issued in favor of the Commission under the number listed above and the confirmation of the Letter of Credit issued under the confirmation number listed above (if any). The Employer agrees that the Letter of Credit and the Confirmation (if any) shall be held by the Commission under the same terms and conditions and for the same purposes as are recited in the Agreement. The Employer acknowledges that as of the date above the following Letter(s) of Credit are being held by the Commission subject to the terms and conditions of the Agreement. NAME OF ISSUING BANK ______________________________________ ______________________________________ ______________________________________ EMPLOYER CORPORATE SEAL LETTER OF CREDIT NUMBER ____________________________________ ____________________________________ ____________________________________ TOTAL AMOUNT OF LETTERS OF CREDIT:
Signature of Employer's representative Name and title

AMOUNT ___________________ ___________________ ___________________ ___________________
Date

_____________________________________________________ _____________________________________________________ This Agreement is approved 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. IC73 5/09 Illinois Workers' Compensation Commission Office of Self-Insurance Administration 4500 S. Sixth Street Springfield, IL 62703 217/785-7084