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ILLINOIS WORKERS' COMPENSATION COMMISSION SELF-INSURER'S ESCROW AGREEMENT RELEASE OF ESCROW DEPOSIT

Release Effective Date: __________________________ Trust No.: Executed by and by __________________________ ____________________________________________________________, as Employer, ____________________________________________________________, 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.

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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 5/09 Illinois Workers' Compensation Commission Office of Self-Insurance Administration 4500 S. Sixth Street Springfield, IL 62703 217/785-7084