ILLI NOIS WOR K ER S COM PENS ATI ON COM M ISSI ON M ULTI PLE S ECUR ITY ENDOR SE M E NT Employer Name: _____________________________________________________________________________ Address: _____________________________________________________________________________ SECUR ITY TYPE OF SECURITY NAME OF SURETY/ESCROW AGENT/ AMOUNT (BOND, ESCROW OR IDENTIFICATION BANK ISSUING LETTER OF CREDIT LETTER OF CREDIT) NUMBER _____________ ___________________ ___________ ______________________________ _____________ ___________________ ___________ ______________________________ _____________ ___________________ ___________ ______________________________ _____________ ___________________ ___________ ______________________________ _____________ ___________________ ___________ ______________________________ _____________ = TOTAL AMOUNT OF SECURITY This Instrument shall be treated as an endorsement to each above listed surety bond, escrow agreement and the agreement to post letter of credit executed in connection with each surety bond, escrow deposit and letter of credit listed above. The parties to this Endorsement shall include each Surety and Escrow Agent named above, as well as the Employer named above if the Employer has posted a letter of credit or an escrow deposit as security for the payment of its obligations as a private self-insurer incurred under the laws of the State of Illinois known as the Workers Compensation Act and the Workers Occupational Diseases Act, both effective July 9, 1951, as amended, (hereinafter collectively called the Acts) . S aid parties agree that the security referred to above shall share pro rata in the liability of the Employer under the Acts as a private self-insurer in accordance with the ratio of the amount listed above for each individual security to the total amount of the security listed above. For these purposes, the liability of the Employer under the Acts shall be construed to include related administrative and defense costs. The pro rata liability of each security as provided herein shall not be increased if any other security listed above proves to be uncollectible for any reason whatsoever. The parties to this Endorsement acknowledge that the Illinois Self-Insurers Advisory Board or its designated representative shall administer and defend all claims under the security furnished by any Employer that becomes an insolvent self-insurer as defined in the Worker Compensation Act. In the event any provision of this Endorsement is deemed to be in violation of law, such provision shall not be deemed to impair the validity of any other provision hereof. This Endorsement may be executed in separate parts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument. American LegalNet, Inc. www.USCourtForms.com>>>> 2 _________________________________________________________________________________________ Signature of Employer/Surety/Escrow Agent Date _________________________________________________________________________________________ Name and title _________________________________________________________________________________________ Signature of Employer/Surety/Escrow Agent Date _________________________________________________________________________________________ Name and title _________________________________________________________________________________________ Signature of Employer/Surety/Escrow Agent Date _________________________________________________________________________________________ Name and title _________________________________________________________________________________________ Signature of Employer/Surety/Escrow Agent Date _________________________________________________________________________________________ Name and title _________________________________________________________________________________________ Signature of Employer/Surety/Escrow Agent 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. IC81 6/05 Illinois Workers Compensation Commission Office of Self-Insurance Administration 701 S. Second Street Springfield, IL 62704 217/785-7084 2 American LegalNet, Inc. www.USCourtForms.com