ILLINOIS WORKERS’ COMPENSATION COMMISSION SELF-INSURER’S SURETY BOND CANCELLATION AMENDMENT AND ACKNOWLEDGEMENT Bond No.: ________________________ Cancellation Effective Date: ________________________ Principal (Employer) Name: _____________________________________________________________________________________ Address: _____________________________________________________________________________________ Surety Name: _____________________________________________________________________________________ Address: _____________________________________________________________________________________ Whereas, the Principal is continuing without interruption as a private self-insurer pursuant to permission granted by the Illinois Workers’ Compensation Commission, and Whereas, the Principal has furnished a new surety bond or other financial security instrument acceptable to the Illinois Workers’ Compensation Commission to guarantee the Principal’s performance as a private self-insurer from and after the Cancellation Effective Date of the Surety Bond listed above, Now, therefore, the Surety Bond listed above is amended, and the Surety thereon hereby is released and discharged. The Surety Bond is cancelled on the Cancellation Effective Date listed above and the Surety’s obligation thereon is void. ________________________________________________ Signature of Surety’s representative Date ________________________________________________ Name and title This cancellation and amendment is acknowledged by the Illinois Workers’ Compensation Commission. ________________________________________________ Chairman Date 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. IC56 5/09 Illinois Workers’ Compensation Commission Office of Self-Insurance Administration 4500 S. Sixth Street Springfield, IL 62703 217/785-7084 American LegalNet, Inc. www.FormsWorkFlow.com