50 Ill. Adm. Code 2909.EXHIBIT A
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.