Fill and Sign the Application for Adjustment for Workers Compensation Illinois Form

ILLINOIS WORKERS’ COMPENSATION COMMISSION APPLICATION FOR ADJUSTMENT OF CLAIM (APPLICATION FOR BENEFITS) A TTENTION . Please type or print. Answer all questions. File three copies of this form. Workers' Compensation Act Occupational Diseases Act Fatal case? No Yes Date of death             Case # Employee/Petitioner (Office use only) v.       Location of accident       Employer/Respondent or last exposure City, State             Injured employee's name 1 Street address, City, State, Zip code             Employer's name Street address, City, State, Zip code Employee information: State employee? Yes No Male Female Married Single #Dependents under age 18       Birthdate       Average weekly wage $       Date of accident 2       The employer was notified of the accident orally in writing How did the accident occur? What part of the body was affected?       What is the nature of the injury?       Return-to-work date 3       Is a Petition for an Immediate Hearing attached? Yes No Is the injured employee currently receiving temporary total disability benefits? Yes No If a prior application was ever filed for this employee, list the case number and its status       A TTENTION , PETITIONER . T his is a legal document. Be sure all blanks are completed correctly and you understand the statements before you sign this. Refer to the Commission's Handbook on Workers' Compensation and Occupational Diseases 4 for more information. ___________________________________________       Signature of petitioner Date A PPEARANCE OF P ETITIONER ' S A TTORNEY Please attach a copy of the Attorney Representation Agreement . ___________________________________________       Signature of attorney Street address             Attorney’s name and IC code # 5 (please print) City, State, Zip code                   Firm name Telephone number E-mail address IC1 5/12 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084 P ROOF OF S ERVICE If the person who signed the Proof of Service is not an attorney, this form must be notarized. If you prefer, you may submit the front of this application form with the Proof of Service on a separate page. I,       , affirm that I delivered mailed with proper postage in the city of       a copy of this form at       AM on       to the respondent listed on this application and to each additional party, if any, at the address listed below.       ________________________________________ Signature of person completing Proof of Service Signed and sworn to before me on ______________ ___________________________________________ Notary Public 1 In most cases, the injured employee files this application and is referred to as the petitioner. If the injury was fatal, or if the worker is a minor or incapacitated, another person (as allowed by law) may file. In those cases, the person filing the application is the petitioner, and the worker is referred to as the injured employee. Please complete information related to age, etc., for the injured employee. 2 This may be the date of the accident, last exposure, disability, or death. 3 If the employee has not returned to work, leave this space blank. 4 The Commission publishes a handbook that explains the workers' compensation system. If you would like a copy, please call any Commission office. 5 The Commission assigns code numbers to attorneys who regularly practice before it. To obtain or look up a code number, contact the Information Unit in Chicago or any of the downstate offices at the telephone numbers listed on this form. IC1 page 2