Office of the Special Deputy Receiver
Representing Dana Popish Severinghaus, Acting Director of the Illinois Department of Insurance
Jacob Stuckey, Special Deputy Receiver & Chief Executive Officer
Information Request Form
In order to serve you properly, we are asking
you to complete this form so that we have all the information we
require to process your request in an expedient manner.
Information that is required is marked with a red asterisk*.
The other information requested may be useful in processing your