Fill and Sign the Illinois Workers Compensation Form

ILLINOIS WORKERS’ COMPENSATION COMMISSION PETITION FOR REVIEW OF ARBITRATION DECISION To appeal an arbitration decision, file two copies of this form within 30 days of receipt of the decision.       Case #       WC       Employee/Petitioner v.             Employer/Respondent The petitioner respondent requests the Commission to review the arbitration decision for this case, filed on       and received on       , and to take the following steps: 1. Furnish a transcript of the arbitration hearings, including all exhibits, to be presented to the Commission. I guarantee to pay for the cost to prepare the transcript within 30 days from the court reporter's written request, even if I later withdraw this appeal, and enter myself as surety therefor. Note: The first party to file a petition will be charged for the cost to prepare the transcript (original rate). Provide       copy/copies of the transcript. I similarly guarantee payment at the copy rate. 2. Extend the time allowed to file the transcript or the agreed statement of facts by 30 days past the time allowed by statute or stipulation. 3. Consider the issues checked below to which I take exception: A CCIDENT Did it occur? Did it arise out of employment? Was it in the course of employment? Is the date correct? B ENEFIT R ATES Are the benefit rates correct? Are the wage calculations correct? E MPLOYMENT Was there an employer-employee relationship? J URISDICTION Does the Commission have jurisdiction? M EDICAL EXPENSES Is there a causal connection? Is the charge reasonable? Was the treatment reasonably necessary? Is prospective medical care necessary? N OTICE Was the respondent given proper notice? O CCUPATIONAL DISEASE Was there an exposure? Was there a disease? Did it arise out of employment? Was it in the course of employment? What was the last date of exposure? O THER (explain)       P ENALTIES AND FEES Section 16 Section 19(k) Section 19(l) P ERMANENT DISABILITY Is there a causal connection? What is the nature and extent of the disability? S TATUTE OF LIMITATIONS Was the case filed within the statute of limitations? T EMPORARY DISABILITY Is there a causal connection? Is the duration of the disability correct? 4. Oral argument: Requested Waived _________________________________             Signature Telephone number Street address             Name (please print; attorneys, include IC attorney code#) City, State, Zip code IC11 12/04 100 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 IC11 page 2