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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. RETURN TO APPLICANT S LEGAL NAME/MAILING ADDRESS/WEB SITE DESIRED SELF-INSURANCE EFFECTIVE DATE Office of Self-Insurance Admin* 4500 S* Sixth St* Frontage Road Springfield IL 62703-5118 SUBSIDIARY A FFILIATE The employer applicant applies for the privilege of being a certified self-insurer in the State of Illinois...

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ILLINOIS FEIN NAICS E-mail IC50s insurer 10-Q selfinsurer incl OSHA deposes compensable IWCC FFILIATE affiant caustics insurers dusts exposures hierarchical injurious liquidation nonrefundable Frontage silica verifies dependents representations communicab

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