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Non-member Companies
 
 

This form is for newly formed companies, or those whose domicile or licenses have changed to allow them to write mine subsidence coverage in Illinois. Upon receipt, the Fund will mail reinsurance agreements and plan documents to the primary contact. A password to the Member Companies section of this website will also be assigned.

Company name:
A.M. Best #:
Group name:
Domicile:
   
Address:
City:
State:
Zip:
Phone:
   

Primary Contact

This person is an officer of the company, or legal counsel, authorized to enter into legal contracts.
Name:
Title:
Department:
Phone:
E-mail:
   
Comments:
   
Reported By
   
Name:
Title:
Phone:
E-mail:
   
Address:
City:
State:
Zip: