Application For Self-Insurance

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ILLINOIS WORKERS’ COMPENSATION COMMISSION
APPLICATION FOR SELF-INSURANCE
FOR SUBSIDIARY OR AFFILIATE
Read all instructions before completing this application. Answer all questions.
R
:
A
’
L
/
/W
S
D
ETURN TO
PPLICANT
S
EGAL NAME
MAILING ADDRESS
EB
ITE
ESIRED
S
-I
ELF
NSURANCE
:
EFFECTIVE DATE
Office of Self-Insurance Admin.
4500 S. Sixth St. Frontage Road
Springfield, IL 62703-5118
S
A
UBSIDIARY
FFILIATE
The employer (applicant) applies for the privilege of being a certified self-insurer in the State of Illinois, as provided in
the Illinois Workers’ Compensation and Occupational Diseases Acts. An applicant may not operate as a certified self-
insurer until the Commission issues a Certificate of Approval to Self-Insure.
1. L
-
.
IST THE COMPANY REPRESENTATIVE FOR SELF
INSURANCE
Name
Title
Company name
Street address
City/State/Zip
Telephone
Fax
E-mail address
2. A
’
F
E
I
N
(FEIN)
PPLICANT
S
EDERAL
MPLOYER
DENTIFICATION
UMBER
3. S
:
Individual
Partnership
Corporation
TATUS
4. N
ATURE OF BUSINESS
Primary NAICS codes
NAICS = North American Industry Classification System, which replaces SIC.
5. I
NCORPORATED OR ORGANIZED UNDER THE LAWS OF
ON
S
THE
TATE OF
6. D
I
ATE OF COMMENCEMENT OF BUSINESS IN
LLINOIS
7. E
XACT LEGAL NAME OF ULTIMATE PARENT
Web site address
FEIN
1

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