ILLI NOIS WOR K ER S COM PENS ATI ON COM M ISSI ON SEL F-I NS UR ER S S UR ET Y BOND GE NE R AL PUR POSE RI DER To be attached to and form a part of the Self-Insurers Surety Bond Bond No.: __________________________ Executed by: ____________________________________________________________ , as Principal (Employer), and by: ____________________________________________________________ , as Surety, in favor of: Illinois Workers Compensation Commission , as Obligee. In consideration of the mutual agreements herein contained the Principal and Surety hereby agree to the following changes: Change Name From: _____________________________________________________________________________ To: _____________________________________________________________________________ Change Amount From: ____________________________________ To: ____________________________________ Addition (A) and Deletion (D) of Principal (Employer) Nothing herein contained shall vary, alter, or extend any provision or condition of the Surety Bond except as expressly stated. PR INCIPAL (EM PLO YER ) COR POR ATE S EAL SUR ET Y COR POR ATE SE AL ___________________________________________ ___________________________________________ Signature of Principal s representative Date Signature of Attorney-In-Fact Date ___________________________________________ ___________________________________________ Name and title 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. IC53 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