Fillable Illinois Workers Compensation Forms printable pdf download

Illinois Workers Compensation Forms

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ILLINOIS WORKERS’ COMPENSATION COMMISSION

SELF-INSURER’S SURETY BOND

GENERAL PURPOSE RIDER

To be attached to and form a part of the Self-Insurer’s Surety Bond

Bond No.:

__________________________

Executed by:

____________________________________________________________ , as Principal (Employer),

and by:

____________________________________________________________ , as Surety,

in favor of:

Illinois Workers’ Compensation Commission

, as Obligee.

In consideration of the mutual agreements herein contained the Principal and Surety hereby agree to the following

changes:

Change Name

From: _____________________________________________________________________________

To:

_____________________________________________________________________________

Change Amount From: ____________________________________ To: ____________________________________

Addition (A) and Deletion (D) of Principal (Employer)

Nothing herein contained shall vary, alter, or extend any provision or condition of the Surety Bond except as expressly

stated.

PRINCIPAL (EMPLOYER) CORPORATE SEAL

SURETY CORPORATE SEAL

___________________________________________

Signature of Principal’s representative

Date

Signature of Attorney-In-Fact

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.

IC53 5/09 IWCC Office of Self-Insurance Administration 4500 S. Sixth St. Frontage Rd. Springfield, IL 62703 217/785-7084