ILLINOIS WORKERS’ COMPENSATION COMMISSION RATE ADJUSTMENT FUND AND SECOND INJURY FUND ASSESSMENT TRANSMITTAL FORM FOR 1/1/2011 – 6/30/2011 ASSESSMENT IS DUE BY SEPTEMBER 15, 2011 Company Name: Attn: Address 1: Address 2: City, State, Zip: SECTION 1. ASSESSMENT CALCULATION A) Total compensation paid from 1/1/11 through 6/30/11 Include ALL compensation payments made under the Illinois Workers’ Compensation Act, whether by lump sum settlement or weekly compensation payments. Do not include hospital, surgical, or rehabilitation payments. Do not subtract subrogation recovery or refunds when calculating compensation payments. $ If no compensation payments were made, enter 0 (zero) on Line A and complete the remainder of the form. B) Rate Adjustment Fund (RAF) assessment rate (NO ASSESSMENT DUE) X 0.0000 C) RAF amount due (Line A x Line B): $ D) Second Injury Fund (SIF) assessment rate X 0.000625 E) SIF amount due (Line A x Line D): $ F) Total amount due (Line C + Line E) $ 0.0 Make check payable to “State Treasurer.” The form must be returned, regardless of the amount provided in Section 1(A). Mail with payment to: Fiscal Office Illinois Workers’ Compensation Commission 100 W Randolph St Ste 8-329 Chicago, IL 60601 American LegalNet, Inc. www.FormsWorkFlow.com SECTION II. MULTIPLE ENTITIES Complete this section if your report includes more than one entity (parent and/or divisions/subsidiaries). Division or Subsidiary Compensation Payments RAF Amount SIF Amount $ $ $ $ $ $ $ $ $ $ $ $ Attach additional sheet if necessary. SECTION III. AFFIDAVIT An officer of the company must complete this section, and the signature must be notarized. , being duly sworn on oath, depose and state that I have read this notice of I, Name assessment, that I am acquainted with the affairs of the employer, and that the representations and statements herein set forth are true in substance and fact. By: _______________________________________ Signature Title Company Company telephone and fax numbers Email address Federal Employer Identification Number NAIC Number, if applicable Subscribed and sworn to before me at __________________________________________ City, State this __________ day of ________ 2011. ________________________________________ Notary Public Disclosure of this information is REQUIRED under Chapter 820 ILCS 305. Failure to provide information will result in a delinquency notice with penalties being issued. American LegalNet, Inc. www.FormsWorkFlow.com