ILLINOIS WORKERS’ COMPENSATION COMMISSION REQUEST FOR INVESTIGATION INTO EMPLOYER'S INSURANCE COVERAGE If you cannot find any information regarding an employer’s insurance coverage, please complete as much of this form as possible and send it to the Insurance Compliance Division, 100 W. Randolph St. #8-200, Chicago, IL 60601 (telephone: 312/814-4783 or toll-free 866/352-3033; email: inscompquestions.wcc@illinois.gov; fax: 312/814-5979). We will not give your name to the employer. Please use one form for each employer. Today’s date: ______________ ___________________________________________________________________________________________________________ Name of employer Employer's owner/manager Type of business ___________________________________________________________________________________________________________ Employer's FEIN Number of employees Web site address ___________________________________________________________________________________________________________ Employer’s telephone Fax number Cell phone Email address ___________________________________________________________________________________________________________ Employer’s street address, city, state, zip code ___________________________________________________________________________________________________________ Job site address, city, state, zip code (if different from above) ___________________________________________________________________________________________________________ Vehicles at job site (include make/model/plate#) ___________________________________________________________________________________________________________ Describe above any work injuries involving this employer ___________________________________________________________________________________________________________ Injured employee's name, if applicable Date of accident Case number ___________________________________________________________________________________________________________ Your name Relationship to employer (if any) ___________________________________________________________________________________________________________ Your telephone Fax number Cell phone Email address ___________________________________________________________________________________________________________ Your street address, city, state, zip code If there is any other information you wish to share, please list it below. ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ IC42 11/06 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084 American LegalNet, Inc. www.FormsWorkflow.com