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ILLINOIS WORKERS' COMPENSATION COMMISSION CERTIFICATE OF EXCESS INSURANCE

This certifies that a Workers' Compensation and Workers' Occupational Diseases Excess Insurance Policy has been issued and delivered to the Employer named below, and that by issuance and delivery of the said policy and the filing of the Certificate of Insurance, it is admitted that said excess policy was effective on the date stated below and that the coverage provided therein is applicable to benefits under the Workers' Compensation and Workers' Occupational Diseases Acts of the State of Illinois and that said policy shall remain in full force and effect until receipt by the Illinois Workers' Compensation Commission of notice of its' cancellation, expiration, or material alteration in accordance with the provisions of Chapter 820, Illinois Compiled Statutes.

Name of Illinois Insured Employer: __________________________________________________________________________ Name of Illinois Subsidiaries and Affiliates covered under this policy: _______________________________________________ ________________________________________________________________________________________________________ Name of Insurer: _________________________________________________________________________________________ Address of Insurer: _______________________________________________________________________________________ Policy No.: _________________________________________ Effective Date: ________________________________ No _____________

Does this Policy apply to coverages other than workers' compensation? Yes _____________

If yes, what other coverages apply? __________________________________________________________________________

FORM OF COVERAGE (ILLINOIS ONLY) Specific Excess Limits: ______________________________________ Aggregate Excess Limits: ___________________________________

Retention: ______________________________________

Retention: ___________________________________

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Signature of Insurer's authorized representative Date

_______________________________________________________________________________________________________
Name and Title

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Address Telephone

Disclosure of this information is required under the Illinois Workers' Compensation Act. Failure to provide information will prevent the form from being processed. IC80 5/09 Illinois Workers' Compensation Commission Office of Self-Insurance Administration 4500 S. Sixth Street Springfield, IL 62703 217/785-7084