TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER hh: WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY
PART 2909 WORKERS' COMPENSATION LARGE DEDUCTIBLE BUSINESS
SECTION 2909.EXHIBIT A COLLATERAL REPORT

 

 

Section 2909.EXHIBIT A   Collateral Report

 

 

COLLATERAL REPORT

 

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

 

 

 

 

(Company Name)

By:

 

(Signature)

Title:

 

Date:

 

Please enter the required information:

 

Policyholder Name

Net Worth

Per Claim

Deductible

Open

Reserves*

Collateral

Held*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**

 

 

 

 

 

*    As calculated pursuant to Section 2909.40(b) of this Part.

**  Add additional rows, if needed, for each policy holder.