Ill. Admin. Code tit. 50, pt. 2909, exh. 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.

Notes

Ill. Admin. Code tit. 50, pt. 2909, exh. A

Adopted at 41 Ill. Reg. 78, effective 12/27/2016.