Public Employers Election To Self-Insure {IC50e}

ILLINOIS WORKERS' COMPENSATION COMMISSION PUBLIC EMPLOYER'S ELECTION TO SELF-INSURE Pursuant to 745 ILCS10/9-103, a local public entity may insure itself under the Illinois Workers' Compensation and Occupational Diseases Acts. Every January 1st, within 30 days, the entity shall file with the Illinois Workers' Compensation Commission a report indicating its election to self-insure. This form serves as that report. Please mail to: Fiscal Office, Illinois Workers' Compensation Commission, 100 W. Randolph Street, Suite 8-200, Chicago, IL 60601. 1. LIST THE EMPLOYER REPRESENTATIVE FOR WORKERS' COMPENSATION SELF-INSURANCE. THIS PERSON WILL RECEIVE INFORMATION REGARDING ASSESSMENTS FOR THE SECOND INJURY AND RATE ADJUSTMENT FUNDS. Name Employer name Address Telephone E-mail address Website 2. EMPLOYER'S FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) 3. ARE YOU A MEMBER OF AN INTERGOVERNMENTAL RISK POOL? If so, please identify it. 4. NATURE OF ORGANIZATION 5. DATE OF COMMENCEMENT OF OPERATION IN ILLINOIS 6. DATE OF SELF-INSURANCE Fax Title _________________________________________ Signature of employer representative ____________________________ Date IC50e 12/14 Illinois Workers' Compensation Commission 100 W. Randolph Street Suite 8-200 Chicago, IL 60601 312/814-1606 iwcc.il.gov American LegalNet, Inc. www.FormsWorkFlow.com