Fill and Sign the Illinois Verification Workers Compensation Form

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