Illinois Workers' Compensation Commission Self-Insurer'S Surety Bond Cancellation Amendment And Acknowledgement Form

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ILLINOIS WORKERS’ COMPENSATION COMMISSION

SELF-INSURER’S SURETY BOND

CANCELLATION AMENDMENT AND ACKNOWLEDGEMENT

Bond No.:

________________________

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.

________________________________________________

Signature of Surety’s representative

Date

________________________________________________

Name and title

This cancellation and amendment is acknowledged by the Illinois Workers’ Compensation Commission.

________________________________________________

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 IWCC Office of Self-Insurance Administration 4500 S. Sixth St. Frontage Rd. Springfield, IL 62703 217/785-7084