ILLINOIS WORKERS’ COMPENSATION COMMISSION REQUEST FOR VERIFICATION OF EMPLOYER'S INSURANCE COVERAGE By law, employers must provide proper workers' compensation benefits. They either purchase insurance policies or, with Commission approval, they may insure themselves. Under Section 6 of the Workers' Compensation Act, the employer must post a notice in each workplace listing the name and address of the insurance company or organization that administers its workers' compensation program. The notice must also include the number of the insurance policy, its effective date, and the date of termination. Each Commission office has a computer terminal, maintained by the National Council on Compensation Insurance, that lists employers' insurance carriers. If the employer does not post the information at work, you may find it on the computer. The Commission also has records on self-insurance pools, which will not be found on the NCCI computer. If you cannot find any insurance information regarding a company, please complete this form and send it to the Insurance Compliance Division, 100 W. Randolph St. #8-200, Chicago, IL 60601 (fax: 312/814-5979) or call toll-free 866/352-3033. We will require the employer to show proof of insurance. We will not give your name to the employer. If appropriate, we will prosecute employers that violate the Act. ________________________________________________________________________________________________________ Name of employer (please note if the employer is incorporated, if known) ________________________________________________________________________________________________________ Name of employer's owner, if known ________________________________________________________________________________________________________ Street address City, State, Zip code ________________________________________________________________________________________________________ Injured employee's name, if applicable Date of accident Case number ________________________________________________________________________________________________________ Your name Phone number ________________________________________________________________________________________________________ Street address City, State, Zip code If there is any other information you wish to share, please list it below. ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ IC42 12/04 100 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.USCourtForms.com