Fill and Sign the Illinois Compensation 497306388 Form

ILLINOIS WORKERS’ COMPENSATION COMMISSION ARBITRATION CASE INFORMATION SHEET A TTENTION . Please complete this form, have both parties sign it, and place it in the arbitrator's message box next to the hearing room door or other area designated by the arbitrator. Do not interrupt the hearings. Be as specific as possible. You must see the arbitrator if your case is above the red line.       Arbitrator       Employee/Petitioner Case #       WC       v. Today’s date             Employer/Respondent Status call date and line #       Please check the appropriate box. Petitioner is receiving TTD. Petitioner is still treating. Name of doctor/clinic:       Date and nature of last treatment:       Petitioner is receiving vocational rehabilitation/job placement services. Date and nature of last service:       Deposition scheduled for       We expect to be ready for trial by       Tentative settlement reached. We will submit contract for approval by       Request for approval of Medicare set-aside was submitted on       The case will be ready for trial by       The case was partially tried on       Next trial date is       Other (explain)       _______________________________________________ ___________________________________________ Signature of petitioner's attorney Signature of respondent's attorney             Name of petitioner's attorney (please print) Name of respondent's attorney (please print)             Email address Email address One-sided or ex parte communication is prohibited. Any correspondence sent to the Commission related to a pending matter must be sent to all parties at the time it is sent to the Commission, and must list the parties to whom copies have been sent. IC41 8/12 100 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