Fill and Sign the Hearing Workers Compensation Illinois Form

ILLINOIS WORKERS’ COMPENSATION COMMISSION PETITION FOR AN IMMEDIATE HEARING UNDER SECTION 19( b ) OF THE ACT Complete both sides of this form.       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 orally in writing to       on       . 5. The employer has refused to pay proper compensation medical benefits . 6. I did did not receive medical treatment for the accident from a medical provider selected by the employer. 7. Name and address of medical provider(s), and dates of treatments:       8. Are any medical bills in dispute? If so, please list.       9. On       , I gave the employer (list name and job title)       the following information stating I am unable to return to work: A recent statement, signed by a medical provider Other (explain)       10. When was the last payment of temporary total disability benefits, if any?       11. In an attempt to resolve the disputed matters,       Petitioner or petitioner's attorney (please print) conferred with       by telephone in person Respondent or respondent's representative on       , but they were unable to resolve this dispute. __________________________________________             Signature of petitioner or petitioner's attorney Date Telephone number A TTENTION , R ESPONDENT . According to Commission Rules, you must file a Response to the Petition for an Immediate Hearing within 15 days from the date this petition was served on you. If you fail to respond in good faith, attorney's fees or penalties may be levied against you. IC7 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. This form must be served on the arbitrator and other parties 15 days before the status call. I,       , affirm that I delivered mailed with proper postage in the city of       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 IC7 Page 2