ILLINOIS WORKERS’ COMPENSATION COMMISSION CERTIFICATE OF EXCESS INSURANCE This certifies that a Workers’ Compensation and Workers’ Occupational Diseases Excess Insurance Policy has been issued and delivered to the Employer named below, and that by issuance and delivery of the said policy and the filing of the Certificate of Insurance, it is admitted that said excess policy was effective on the date stated below and that the coverage provided therein is applicable to benefits under the Workers’ Compensation and Workers’ Occupational Diseases Acts of the State of Illinois and that said policy shall remain in full force and effect until receipt by the Illinois Workers’ Compensation Commission of notice of its’ cancellation, expiration, or material alteration in accordance with the provisions of Chapter 820, Illinois Compiled Statutes. Name of Illinois Insured Employer: __________________________________________________________________________ Name of Illinois Subsidiaries and Affiliates covered under this policy: ______________________________________________ _______________________________________________________________________________________________________ Name of Insurer: ________________________________________________________________________________________ Address of Insurer: _______________________________________________________________________________________ Policy No.: ____________________________ Effective Date: ________________ Expiration Date: _______________ Does this Policy apply to coverages other than workers’ compensation? Yes _____________ No _____________ If yes, what other coverages apply? __________________________________________________________________________ FORM OF COVERAGE (ILLINOIS ONLY) Specific Excess Aggregate Excess Limits: Limits: ______________________________________ Retention: ______________________________________ ___________________________________ Retention: ___________________________________ Corridor Deductible: ______________________________ (If the policy contains a corridor deductible, include policy, amendment or endorsement specifying the terms.) _______________________________________________________________________________________________________ Signature of Insurer’s authorized representative Date _______________________________________________________________________________________________________ Name Title _______________________________________________________________________________________________________ Address Telephone Disclosure of this information is required under the Illinois Workers’ Compensation Act. Failure to provide information will prevent the form from being processed. IC80 5/10 Illinois Workers’ Compensation Commission Office of Self-Insurance Administration 4500 S. Sixth St. Frontage Rd. Springfield, IL 62703-5118 217/785-7084 American LegalNet, Inc. www.FormsWorkFlow.com