ILLINOIS WORKERS’ COMPENSATION COMMISSION INJURED WORKERS’ BENEFIT FUND: REQUEST TO CERTIFY LACK OF INSURANCE COVERAGE Attorneys: Complete this form only if you have searched the online database for employer’s insurance coverage and have been unable to find coverage. Please fax this form and copies of any relevant information, e.g., W-2s, Application of Adjustment of Claim, and an employee’s paycheck stub to the Insurance Compliance Division at 312/814-5979. _________________________________ Case # ____ WC ___________ Employee/Petitioner v. _________________________________ Employer/Respondent Date(s) of injury ___________________________________________________________________ Location of injury ___________________________________________________________________ Employer’s name ___________________________________________________________________ Owner(s)/Officer(s) ___________________________________________________________________ Employer’s address(es) ___________________________________________________________________ Employer’s FEIN(s) ___________________________________________________________________ (Federal Employer Identification Number) If Temporary/PEO service, name and address of servicer ___________________________________________________________________ ___________________________________________________________________ If construction company, please include the site address ___________________________________________________________________ I certify that I have searched the NCCI online database for insurance for this case and did not find policy information for this employer. _________________________________________ _________________________________________ Name Signature Date ___________________________________________________________________________________________________________ Your street address, city, state, zip code Due to heavy demand, please allow a minimum of four weeks for a reply to this request for certification. Making multiple requests will only delay the requested information. IC43 11/08 100 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