Request For Information On Employers Insurance Coverage {IC46}

ILLINOIS WORKERS' COMPENSATION COMMISSION REQUEST FOR INFORMATION ON 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 Information Department, 100 W. Randolph St. #8-200, Chicago, IL 60601. We will not give your name to the employer. Please use a separate form for each employer. ____________________________ Today's Date __________________________________ Name of Business ______________________________ Owner/Manager Name _________________________ Business telephone ____________________________________________________________________ Employer's Street Address, City, State, Zip _________________________ Employer's FEIN ____________________________________________________________________ Jobsite Street Address, City State, Zip (if different from above) _________________________ Number of Employees __________________________________ Injured Employee's Name ______________________________ Date of Accident _________________________ WC Case # __________________________________ Your Name ______________________________ Relationship to employee (if any) _________________________ Your Telephone # ____________________________________________________________________ Your Address, City, State, Zip _________________________ Your E-mail A written response of insurance coverage or no coverage information will be forwarded to you. For Office Use Only: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ IC46 12/12 100 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