Fill and Sign the Illinois Request Hearing Form

ILLINOIS WORKERS’ COMPENSATION COMMISSION REQUEST FOR HEARING A TTENTION . Please give this form to the Arbitrator after you obtain a trial date. Case #       WC             Employee/Petitioner Consolidated cases:       v.       Setting       Employer/Respondent Petitioner and Respondent are prepared to try this matter to completion on       , unless the Arbitrator approves other arrangements. 1. Petitioner claims that, on       , Petitioner and Respondent were operating under the Illinois Workers' Compensation or Occupational Diseases Act, and their relationship was one of employee and employer. Respondent agrees disputes . 2. Petitioner claims that, on the above date, he or she sustained accidental injuries or was last exposed to an occupational disease that arose out of and in the course of employment. Respondent agrees disputes . 3. Petitioner claims Respondent was given notice of the accident within the time limits stated in the Act. Respondent agrees disputes . If in dispute, Petitioner states that on       , notice was given to       , with the job title       . 4. Petitioner claims his or her current condition of ill-being is causally connected to this injury or exposure. Respondent agrees disputes . 5. Petitioner claims his or her earnings during the year preceding the injury were $       , and the average weekly wage, calculated pursuant to Section 10 of the Act, was $       . Respondent agrees disputes and claims       6. At the time of injury, Petitioner was       years old; married single ; with       dependent children. Respondent agrees disputes and claims       7. Petitioner claims Respondent is liable for the following unpaid medical bills: Attach a list, if necessary.       Respondent agrees disputes and claims       Respondent claims it paid $       in medical bills through its group medical plan for which credit may be allowed under Section 8(j) of the Act. Petitioner agrees disputes and claims       IC9 2/10 100 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 8. Petitioner claims to be entitled to (Attach a sheet if necessary to list additional periods.) TTD period(s):       , representing       weeks. First day of lost time through Last day of lost time Respondent agrees disputes and claims       TPD period(s):       , representing       , weeks. First day through Last day Respondent agrees disputes and claims       Maintenance period(s):       , representing       weeks. First day through Last day Respondent agrees disputes and claims       9. Respondent claims it paid $       in TTD, $       in TPD, $       in maintenance, $       in nonoccupational indemnity disability benefits, and $       in other benefits, for which credit may be allowed under § 8(j) of the Act. Petitioner agrees disputes and claims       10. The nature and extent of the injury is is not in dispute. 11. Petitioner claims to be entitled to penalties/attorney’s fees under §19(k) §19(l) and/or §16 . Petitioner has has not filed a penalty petition. 12. A petition for attorney’s fees by a former attorney is is not pending. Petitioner’s attorney has notified the former attorney of the date of this hearing. 13. Other issues, not listed above, are:       14. S TENOGRAPHIC STIPULATION . Both parties agree that if either party files a Petition for Review of Arbitration Decision and orders a transcript of the hearings, and if the Commission's court reporter does not furnish the transcript within the time limit set by law, the other party will not claim the Commission lacks jurisdiction to review the arbitration decision because the transcript was not filed timely. A written decision, including findings of fact and conclusions of law, is requested pursuant to Section 19(b).             Date submitted Name of Respondent's insurance or service company __________________________________________________ ________________________________________________ Signature of Petitioner or Petitioner's attorney Signature of Respondent or Respondent's attorney             Attorney’s name and IC code # Attorney’s name and IC code #             Name of law firm Name of law firm             Street address Street address             City, State, Zip code City, State, Zip code                         Telephone number Email address Telephone number Email address N OTE : The arbitration decision will be sent by certified mail to the addresses listed above. IC9 p. 2