Fillable Illinois Workers Compensation Forms (Page 2 of 2) in pdf

Payment of Proceeds. The Surety hereon does hereby recognize this Bond as a direct financial guarantee to Principal’s

employees, whether they be known, unknown or unnamed, and that Principal’s employees are hereby authorized to

maintain direct action on this Bond, including action for reasonable attorney’s fees incurred in any action brought on this

Bond. The Surety shall have the right to administer and defend all claims under the Bond. However, the Illinois Self-

Insurers Advisory Board, pursuant to statute in such case made and provided, may make demand upon Surety for the

payment of the Bond Amount or so much as required thereof to the Illinois Self-Insurers Security Fund for the sole

purpose of discharging Surety’s obligations hereunder. After such demand has been made, no employee shall maintain a

direct action on this Bond and the Surety shall not make any payment under the Bond to any employee. Surety shall be

released from liability under this Bond to the extent of any payment made to the Illinois Self-Insurers Security Fund.

One year after all obligations owed to the employees of the Principal under the provisions of the Acts have been satisfied

and paid, any funds from this Bond remaining on deposit in the Illinois Self-Insurers Security Fund shall be returned to

the Surety.

Subrogation. If the Surety becomes liable for any payment under this Bond for injuries or exposures of the Principal’s

employees, the Surety shall be subrogated, to the extent of such payment, to any of the rights and remedies of the

Principal against any party in respect of said injuries or exposures and shall be entitled at Surety’s own expense to sue in

the name of the Principal. The Principal shall give Surety all such assistance in its power as Surety may require to secure

Surety’s rights and remedies and, at Surety’s request shall execute all documents necessary to enable Surety effectively to

bring suit in the name of the Principal, including the execution and delivery of the customary form of loan receipt.

Cancellation. The Surety or Principal shall have the right to cancel this Bond at any time, upon giving the other party

and the Illinois Workers’ Compensation Commission at least sixty (60) days prior written notice of its desire to do so.

Such cancellation, however, shall not affect the Surety’s liability as to any amounts then due or thereafter to become due

hereunder as the result of injuries or exposures occurring prior to the date of cancellation specified in such notice;

provided that if immediately following such cancellation date and without interruption Principal continues as a qualified

private self-insurer under the Acts for which a subsequent surety bond or other financial security for the benefit of

Principal’s employees is issued, the Surety hereon is released from all liability under this Bond for injuries or exposures

whensoever they occurred, and Surety’s obligation hereunder shall be void.

Signed, sealed and delivered on the date below.

PRINCIPAL (EMPLOYER) CORPORATE SEAL

SURETY CORPORATE SEAL

__________________________________________

Signature of Principal’s representative

Signature of Attorney-In-Fact

__________________________________________

Name and title

__________________________________________

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.

IC52 5/09 IWCC Office of Self-Insurance Administration 4500 S. Sixth St. Frontage Rd. Springfield, IL 62703 217/785-7084

Illinois Workers Compensation Forms Page 2

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