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 SEL F-ADM I NIS TER E D CL AI M S E NDORSE M E NT Bond No.: ________________________ Executed by __________________________________________________________ , as Principal (Employer) and by __________________________________________________________ , as Surety. Whereas, the Principal on the above Self-Insurers Surety Bond has applied to the Illinois Workers Compensation Commission to self-administer all claims made by Principals employees while the Principal is a private self-insurer. Now, therefore, as a condition of granting the Principal permission to self-administer said claims, the Surety and Principal hereon agree that the obligation under this Surety Bond is extended to include payment of all related costs of defense, including the fees and costs of administrators appointed by the Surety or Illinois Self-Insurers Advisory Board for the administration and defense of claims by Principals employees as a result of injuries or exposures covered by the Surety Bond. _____________________________________________ ____________________________________________ Signature of Principal s representative Date Signature of Surety s representative 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. IC55 6/05 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