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Fill and Sign the Illinois Notice Motion Form

Fill and Sign the Illinois Notice Motion Form

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ILLINOIS WORKERS’ COMPENSATION COMMISSION NOTICE OF MOTION AND ORDER A TTENTION . You must attach the motion to this notice. If the motion is not attached, this form may not be processed. Upon filing of a motion before a Commissioner on review, the moving party is responsible for payment for preparation of the transcript.       Case #       WC       Employee/Petitioner v.             Employer/Respondent TO:       On       , at       AM , or as soon thereafter as possible, I shall appear before the Honorable       , or any arbitrator or commissioner appearing in his or her place at       , Illinois, and present the attached motion for: Change of venue (#3072) Consolidation of cases (#3071) (list case#)       Dismissal of attorney (#3052) Dismissal of review (#3085) Fees under Section 16 (#1600) Fees under Section 16a (#1645) Hearing under Sect.19(b) (#1902) Penalties under Sect. 19(k) (#1911) Penalties under Sect. 19(l) (#1912) Reinstatement of case (#3074) Request for hearing (#R33) Withdrawal of attorney (#3073) Other (explain)       _______________________________       Signature Petitioner Respondent Street address             Attorney’s name and IC code # (please print) 1 City, State, Zip code                   Name of law firm, if applicable Telephone number E-mail address O RDER The motion is set for hearing on ___________ ____________________________________________ _______________________ Signature of arbitrator or commissioner Date O RDER The motion is ___ Granted ___ Withdrawn ___ Continued to ________________ ___ Denied ___ Dismissed ___ Set for trial (date certain) on ________________ ____________________________________________ _______________________ Signature of arbitrator or commissioner Date IC4 4/11 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free line 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. 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 Workers’ Compensation Commission assigns code numbers to attorneys who regularly practice before it. To obtain or look up a code number, contact the Information Unit in Chicago or any of the downstate offices at the telephone numbers listed on this form. IC4 page 2

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