Fill and Sign the Illinois Appearance Form

ILLINOIS WORKERS’ COMPENSATION COMMISSION APPEARANCE OF REPRESENTATIVE Please see the other side of this form.       Case #       WC       Employee/Petitioner v.             Employer/Respondent I hereby enter my appearance as counsel co-counsel for the  petitioner respondent . ______________________________________________       Signature of attorney Firm's name             Attorney's name and IC attorney code# 1 (please print) Street address                   Telephone number E-mail address City, State, Zip code       Name of respondent's insurance/service company (please print) A TTENTION , A TTORNEY . A co-counsel appearance must be accompanied by a copy of the original Attorney Representation Agreement with the co-counsel's signature. Please indicate where the Commission should send notices: Name and address listed above       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 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 1 The Commission assigns code numbers to attorneys who regularly appear before it. To obtain or look up a code number, contact the Information Unit in the Chicago office or any of the downstate offices at the telephone numbers listed below. IC6 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 R EJECTION OF A PPEARANCE Date _______________________ To: __________________________________________________ __________________________________________________ __________________________________________________ Your appearance has been rejected for the following reason(s): _____ No case number is listed. _____ The wrong case number is listed. _____ You did not attach the Attorney Representation Agreement. This is required for a petitioner's counsel. _____ You did not provide a copy of the original Attorney Representation Agreement with your signature. This is required for a petitioner's co-counsel. _____ Proof of service was not provided. _____ You did not indicate where notices should be sent. _____ Another attorney is listed as counsel, and he or she has not withdrawn or been dismissed. _____ Other: _________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ If you have questions, please contact any Commission office. Return the corrected form to: D ATA E NTRY U NIT I LLINOIS W ORKERS ’ C OMPENSATION C OMMISSION 100 W. R ANDOLPH S TREET #8-200 C HICAGO , IL 60601 IC6 page 2