BOND - WOR KER S COMP ENS ATION 3514 Rev. (07/05) UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT CASE NUM BER PETITIONER VS. INDUSTRIAL COMMISSION OF ILLINOIS AND INDUSTRIAL COM MISSION NUM BER RESPONDENTS BOND - WORKERS COMPENSATION On , 20 , an award of $ for against was rendered by the Industrial Commission of Illinois in Case Number . A Summons has been issued by this Court to review award, the pursuant to the Notice of commencement of Suit. If the principal shall not successfully prosecute the case, we jointly and severally agree to pay the award as it becomes due and payable, and costs of the proceedings in this Court. . The obligation of this bond is limited to $ Principal Surety Name: PRO SE ENTER: DuPage Attorney Number: Attorney for: Address: JUDGE City/State/Zip: Dated Telephone: CHR IS KACHIR OUBAS, CL ERK OF THE 18TH J UDICIAL CIRCUIT COURT WHEATON, IL LINOIS 60189-0707