Fill and Sign the Illinois Notice Hearing Form

                       Case #                   Setting                                                                                                       , at       before Arbitrator       I in room #             Continue case to       /       /       The petition is insufficient. The petitioner shall file a corrected petition by       /       /       . Set case for trial on                                                 ILLINOIS INDUSTRIAL COMMISSION NOTICE OF PRETRIAL HEARING UNDER SECTION 19(b-1) OF THE ACT ATTENTION, ARBITRATOR. Send this form, with the order section completed, to the 19(b- 1) unit immediately after the pretrial. ATTENTION, RESPONDENT. On/ / I the petitioner filed a Petition for Immediate Hearing under Section 19(b-1) of the Act for this case. You must file a response within 15 days from the date you received notice that the petition was filed with the Commission; failure to respond will prevent you from presenting evidence in defense of this claim. WC Employee/Petitioner V. Employer/Respondent Sent by certified mail to: (return receipt requested) Date of notice / / Name of petitioner or petitioner's attorney (please print) Name of respondent or respondent's attorney (please print) Street address Street address City State Zip code City State Zip code You are hereby notified that this case is set for a pretrial hearing on / / at The parties shall give the following items to the arbitrator on the pretrial date: 1. A completed Request for Hearing form; 2. A list of witnesses who are to be presented by each party at trial; 3. An itemized list of all disputed medical bills, if any, and respondent's objections, if any, to each bill; 4. A list of evidence and the form in which it will be offered (reports, depositions, live testimony, etc.); 5. Any other information relevant to the trial. Any objections to the sufficiency of the petition must be presented at the pretrial hearing. ORDER / / Signature of arbitrator Date / / IC14c 6/99 100 W. Randolph Street #8-200 Chicago, Ill., 60601 312/814-6611 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084