ILLI NOIS WOR K ER S COM PENS ATI ON COM M ISSI ON SEL F-I NS UR ER S E SCR OW AGR EE M ENT AM ENDM E NT To be attached to and form a part of the Self-Insurer s Escrow Agreement Trust No. _______________________________ Executed by ___________________________________________________________________ , as Employer, and by ___________________________________________________________________ , as Escrow Agent, in favor of: Illinois Workers Compensation Commission , as Obligee. In consideration of the mutual agreements herein contained the Employer and Escrow Agent hereby agree to the following changes: Change Name From: __________________________________________________________________________ To: __________________________________________________________________________ Change Amount From: __________________________________ To: ___________________________________ Addition (A) and Deletion (D) of Employer Nothing contained herein shall vary, alter, or extend any provision or condition of the Escrow Agreement except as expressly stated. EM PL OYER COR POR ATE SE AL BANK COR POR ATE S EAL _____________________________________________ __________________________________________ Signature of Employer s representative Date Signature of Escrow Agent s representative Date _____________________________________________ __________________________________________ Name and title Name and title __________________________________________ Signature of Attestant 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. IC63 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