Self-Insurers Escrow Agreement Release Of Escrow Deposit {IC64}

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 R EL EAS E OF ESCR OW DE POSIT Release Effective Date: __________________________ Trust No.: __________________________ Executed by ____________________________________________________________, as Employer, and by ____________________________________________________________, as Escrow Agent. Whereas, the Chairman of the Illinois Workers Compensation Commission has determined that there is no longer any need for the Employer to maintain the Escrow Deposit under the above-captioned Trust Number Agreement. Now, therefore, the Escrow Agent is hereby authorized to release the Escrow Deposit to the Employer. ____________________________________________ Chairman of the Illinois Workers Compensation Commission 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. IC64 5/05 Illinois Workers Compensation Commission Office of Self-Insurance Administration 701 S. Second Street Springfield, IL 62704 217/785-7084 American LegalNet, Inc.American LegalNet, Inc. www.USCourtForms.comwww.USCourtForms.com