Ill. Admin. Code tit. 50, § 2909.EXHIBIT A
| 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.