Fill and Sign the Arbitration Decision Form

ILLINOIS WORKERS’ COMPENSATION COMMISSION PETITION FOR REVIEW OF ARBITRATION DECISION UNDER SECTION 19( b -1) OF THE ACT Please file two copies of this form.       Case #       WC       Employee/Petitioner v.             Employer/Respondent The petitioner respondent requests the Commission to review the arbitration decision for this case, filed on       and received on       , and to take the following steps: 1. Furnish       transcripts of the arbitration hearings regarding the Section 19(b-1) petition, including all exhibits. The transcript was was not ordered at arbitration. I have paid $       to the court reporter and enclose a copy of the check. I guarantee payment for the cost to prepare and copy the transcripts, even if I withdraw this appeal, within 30 days from the court reporter's written request, and enter myself as surety therefor. 2. Consider the issues checked below to which I take exception: A CCIDENT Did it occur? Did it arise out of employment? Was it in the course of employment? Is the date correct? B ENEFIT R ATES Are the benefit rates correct? Are the wage calculations correct? E MPLOYMENT Was there an employer-employee relationship? J URISDICTION Does the Commission have jurisdiction? M EDICAL EXPENSES Is there a causal connection? Is the charge reasonable? Was the treatment reasonably necessary? Is prospective medical care necessary? N OTICE Was the respondent given proper notice? O CCUPATIONAL DISEASE Was there an exposure? Was there a disease? Did it arise out of employment? Was it in the course of employment? What was the last date of exposure? O THER (explain)       P ENALTIES AND FEES Section 16 Section 19(k) Section 19(l) S TATUTE OF LIMITATIONS Was the case filed within the statute of limitations? T EMPORARY DISABILITY Is there a causal connection? Is the duration of the disability correct? I offer the following testimony or exhibits to support my petition: (Cite page/exhibit #, legal references , etc .)       _________________________________             Signature Telephone number Street address             Name (please print; attorneys, include IC attorney code#) City, State, Zip code IC11a 12/04 100 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. I,       , affirm that I delivered sent by certified mail (return receipt requested) a copy of this form at       AM on       to each party at the address(es) listed below.       ____________________________________________ Signature of person completing Proof of Service Signed and sworn to before me on ___________________ ______________________________________________ Notary Public IC11a page 2