Illinois Administrative Code
Title 50 - INSURANCE
Part 2909 - WORKERS' COMPENSATION LARGE DEDUCTIBLE BUSINESS
Exhibit A - Collateral Report
Universal Citation: 50 IL Admin Code ยง A
Current through Register Vol. 48, No. 12, March 22, 2024
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COLLATERAL REPORT |
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Annual Disclosure |
Large Deductible Supplement 215 ILCS 5/155.44 and 136 and 50 Ill. Adm. Code 2909.60 |
Due Date: March 1 each calendar year |
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____________________________________________________________________ (Company Name) |
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By: _________________________________________________________________ |
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(Signature) |
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Title: _________________________________________________ |
Date:_______ |
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Please enter the required information:
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Policyholder Name |
Net Worth |
Per Claim Deductible |
Open Reserves* |
Collateral Held* |
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** |
* As calculated pursuant to Section 2909.40(b) of this Part.
** Add additional rows, if needed, for each policy holder.
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