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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: [email protected]; 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

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Employer's FEIN Number of employees Web site address

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Employer's telephone Fax number Cell phone Email address

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Employer's street address, city, state, zip code

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Job site address, city, state, zip code (if different from above)

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Vehicles at job site (include make/model/plate#)

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Describe above any work injuries involving this employer

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Injured employee's name, if applicable Date of accident Case number

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Your name Relationship to employer (if any)

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Your telephone Fax number Cell phone Email address

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Your street address, city, state, zip code

If there is any other information you wish to share, please list it below.
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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