Office of the Special Deputy Receiver

Representing Dana Popish Severinghaus, Director of the Illinois Department of Insurance

Jacob Stuckey, Special Deputy Receiver & Chief Executive Officer

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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 request.

First Name*:
Last Name*:
Company Name:
Address*:
Address:
City*:
State*:
Zip Code*:
Phone Number:
Fax Number:
E-mail Address: ( For response by e-mail )
Regarding*:	Please choose a company Affirmative Insurance Company American Country Insurance Company American Manufacturers Mutual Insurance Company American Motorists Insurance Company American Service Insurance Company Constitutional Casualty Company Family Health Network, Inc. Gateway Insurance Company Illinois Movers' & Warehousemen's Risk Management Group Land of Lincoln Mutual Health Insurance Company Legion Indemnity Company Lumbermens Mutual Casualty Company Millers Classified Insurance Company Millers First Insurance Company Public Service Insurance Company Public Service Mutual Holding Company Triad Guaranty Assurance Corporation Triad Guaranty Insurance Corporation Webmaster
Please use the space provided below for your request*

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