Fill and Sign the Fy 20 Statement of Work Tdem 17 a Texas Emergency Form

ILLINOIS WORKERS’ COMPENSATION COMMISSION PETITION FOR IMMEDIATE HEARING UNDER SECTION 19(b-1) OF THE ACT ATTENTION. Complete both sides of this form. The petitioner must certify the respondent received this petition and attachments 15 days before it is filed with the Commission. Case # ______ WC __________________ _____________________________________________ Employee/Petitioner v. _____________________________________________ Employer/Respondent I, the petitioner, request an immediate hearing in this matter. I am unable to return to work at this time because of the injuries or disability caused by my employment, and I am not receiving Temporary Total Disability benefits or medical benefits. I further provide the following information: 1. Date, time, and location of accident _______________ _______________ _______________ Date Time Location 2. Description of accident ____________________________________________________________________ 3. Nature of injury ____________________________________________________________________ 4. Notice of the accident was given to __________________________________________________________________ orally ___ in writing ___ on ___________________ . 5. The employer has refused to pay proper compensation ___ medical benefits ___ . 6. When was the last payment of Temporary Total Disability benefits, if any? ___________________________________ 7. I did ___ did not ___ receive medical treatment for the accident from a medical provider selected by the employer. 8. Name and address of medical provider(s), and dates of treatments: _______________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 9. In an attempt to obtain compensation and/or medical benefits, _____________________________________________ Petitioner or petitioner's attorney conferred with __________________________________________________ by telephone ___ in person ____ Respondent or respondent's representative on ________________________ , but they were unable to resolve this dispute. Date IC14a 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 10. Name and address of each witness to the accident, and any other person who will support the employee's allegations: ATTENTION, PETITIONER. You must submit the following items with this petition: 11. A recent statement, signed by a medical provider, that you are unable to return to work because of the accident, and such other documents that show you are entitled to benefits: a) your history of the accident; b) a description of the injury and medical diagnosis; c) the medical services you have received and are now receiving; d) the physical activities you cannot currently perform because of this injury; and e) the prognosis for recovery. 12. A signed authorization for the employer to review all related medical records; 13. Complete copies of any documents in your possession that will support your allegations, provided the employer pays reasonable copying costs; and 14. A list of all documents you have demanded by subpoena that will support your allegations. _______________________________________________ ______________________________________________________ Signature of petitioner or petitioner's attorney Name (please print; attorneys, please include IC attorney code #) Date _______________________________________________ _______________________________________________________ Street address Telephone number ______________________________________________ City, State, Zip code ATTENTION, RESPONDENT. Send this petition to your insurance carrier or claims office immediately. According to Commission Rules, you must file a Response to the Petition for an Immediate Hearing within 15 days from the date you received notice that this petition was filed with the Commission. If you fail to respond, you will not be able to introduce evidence in defense of this claim. 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 IC14a Page 2