Fillable Illinois Workers' Compensation Form printable pdf download

Illinois Workers' Compensation Form

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ILLINOIS WORKERS’ COMPENSATION COMMISSION

SELF-INSURER’S SURETY BOND

SELF-ADMINISTERED CLAIMS ENDORSEMENT

Bond No.:

________________________

Executed by

__________________________________________________________ , as Principal (Employer)

and by

__________________________________________________________ , as Surety.

Whereas, the Principal on the above Self-Insurers’ Surety Bond has applied to the Illinois Workers’

Compensation Commission to self-administer all claims made by Principal’s employees while the Principal is a private

self-insurer.

Now, therefore, as a condition of granting the Principal permission to self-administer said claims, the Surety and

Principal hereon agree that the obligation under this Surety Bond is extended to include payment of all related costs of

defense, including the fees and costs of administrators appointed by the Surety or Illinois Self-Insurers’ Advisory Board

for the administration and defense of claims by Principal’s employees as a result of injuries or exposures covered by the

Surety Bond.

_____________________________________________

____________________________________________

Signature of Principal’s representative

Date

Signature of Surety’s representative

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.

IC55 5/09 IWCC Office of Self-Insurance Administration 4500 S. Sixth St. Frontage Rd. Springfield, IL 62703 217/785-7084