Illinois Workers Compensation Forms

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ILLINOIS WORKERS’ COMPENSATION COMMISSION
SELF-INSURER’S SURETY BOND
Bond No.:
____________________
Bond Amount:
$ ____________________
Date Self-Insurance
Privilege Granted: ____________________
Principal (Employer)
Name:
______________________________________________________________________________
Address:
______________________________________________________________________________
Surety
Name:
______________________________________________________________________________
Address:
______________________________________________________________________________
KNOW ALL MEN BY THESE PRESENTS that we, the undersigned Principal and the Surety, an authorized insurer in
the State of Illinois, are held and firmly bound unto the people of the State of Illinois for the use and benefit of all
employees of the Principal who may be entitled to compensation under laws of the State of Illinois known as the Workers’
Compensation Act, effective July 9, 1951, as amended, and the Workers’ Occupational Diseases Act, effective July 9,
1951, as amended, (hereinafter collectively called the “Acts”) in the stated Bond Amount, for the payment of which sum
we bind ourselves, our successors, and assigns, jointly and severally firmly by these presents, as hereinafter provided.
Principal is an employer which has been granted permission by the Illinois Workers’ Compensation Commission to
provide and pay the compensation benefits provided for in the Acts without insurance, for which Principal is required to
provide security guaranteeing payment by the Principal of the amounts due to the employees of Principal under the Acts.
The condition of the foregoing obligation is such that if the Principal shall pay or cause to be paid direct to Principal’s
employees the amounts due or that may become due under the Acts as the result of injuries and exposures occurring at any
time subsequent to the date of the granting of permission as a private self-insurer under the Acts and the cost of defense
related thereto, then this obligation shall be void; otherwise, it is to be and remain in full force and effect.
Limit of Liability. Notwithstanding the number of claimants or the number of times that the Bond is renewed or
premium is paid, there shall be only one Bond Amount, and in no event shall the aggregate liability of the Surety,
including the costs of defense, exceed the single Bond Amount shown above.

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