Fillable Illinois Workers Compensation Forms printable pdf download

Illinois Workers Compensation Forms

Download a blank fillable Illinois Workers Compensation Forms in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Illinois Workers Compensation Forms with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ILLINOIS WORKERS’ COMPENSATION COMMISSION

SELF-INSURER’S ESCROW AGREEMENT

AMENDMENT

To be attached to and form a part of the Self-Insurer’s Escrow Agreement

Trust No.

_______________________________

Executed by

___________________________________________________________________ , as Employer,

and by

___________________________________________________________________ , as Escrow Agent,

in favor of:

Illinois Workers’ Compensation Commission

, as Obligee.

In consideration of the mutual agreements herein contained the Employer and Escrow Agent hereby agree to the following

changes:

Change Name

From: __________________________________________________________________________

To:

__________________________________________________________________________

Change Amount From: __________________________________ To: ___________________________________

Addition (A) and Deletion (D) of Employer

Nothing contained herein shall vary, alter, or extend any provision or condition of the Escrow Agreement except as

expressly stated.

EMPLOYER CORPORATE SEAL

BANK CORPORATE SEAL

_____________________________________________

__________________________________________

Signature of Employer’s representative

Date

Signature of Escrow Agent’s representative

Date

_____________________________________________

__________________________________________

Name and title

__________________________________________

Signature of Attestant

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.

IC63 5/09 IWCC Office of Self-Insurance Administration 4500 S. Sixth St. Frontage Rd. Springfield, IL 62703 217/785-7084