IL L INOIS WOR KER S COM PENSATION COM M ISSION SEL F -INSUR ER S AGR E EM ENT TO POST L E TTER OF CR EDIT SCHEDUL E OF SUPPL EM ENT To be attached to and form a part of the Self-Insurer s Agreement to Post Letter of Credit Date: __________________ Employer Name: ________________________________________________________________________________________________ Address: ________________________________________________________________________________________________ Issuing Bank Name: __________________________________________________________________ LOC No.: ________________ Address: __________________________________________________________________ Amount $: ________________ Confirming Bank Name: __________________________________________________________________ Confirmation No.: ___________ Address: ________________________________________________________________________________________________ Whereas, the Employer has previously entered into a Self-Insurers Agreement to Post L etter of Credit ( Agreement ) to which this Schedule is attached; and Whereas, the Employer wishes to supplement one or more of the letter(s) of credit ( Letter of Credit ) deposited with the Illinois Workers Compensation Commission ( Commission ) pursuant to the terms of the Agreement and/or pursuant to the terms of any other schedule(s) attached thereto. Now, therefore, as a condition of its continued qualification for the self-insurance privilege or for the use and benefit of its employees as a former self-insurer, the Employer is depositing with the Commission the irrevocable L etter of Credit issued in favor of the Commission under the number listed above and the confirmation of the Letter of Credit issued under the confirmation number listed above (if any). The Employer agrees that the L etter of Credit and the Confirmation (if any) shall be held by the Commission under the same terms and conditions and for the same purposes as are recited in the Agreement. The Employer acknowledges that as of the date above the following L etter(s) of Credit are being held by the Commission subject to the terms and conditions of the Agreement. NAME OF ISSUING BANK LETTER OF CREDIT NUM BER AMOUNT ______________________________________ ____________________________________ ___________________ ______________________________________ ____________________________________ ___________________ ______________________________________ ____________________________________ ___________________ EM PL OYER C OR POR ATE SEA L TOTAL AMOUNT OF LETTERS OF CREDIT: ___________________ _____________________________________________________ Signature of Employer s representative Date _____________________________________________________ Name and title This Agreement is approved by the Illinois Workers Compensation Commission _____________________________________________________ Chairman 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. IC73 5/05 Illinois Workers Compensation Commission Office of Self-Insurance Administration 701 S. Second Street Springfield, IL 62704 217/785-7084 American LegalNet, Inc. www.USCourtForms.com