Fill and Sign the Petition Review Form

ILLINOIS WORKERS’ COMPENSATION COMMISSION PETITION FOR REVIEW UNDER SECTION 19( h ) OR 8( a ) OF THE ACT Please file two copies of this form.       Case #       WC       Employee/Petitioner v.             Employer/Respondent Today,       , the petitioner respondent petitions the Commission to review this case under Section 19(h) 1 Section 8(a) 2 of the Act. I also ask the Commission to furnish       transcripts of the arbitration hearings, including all exhibits. I guarantee payment for the cost to prepare and copy the transcripts, even if I later withdraw this petition, within 30 days from the court reporter's written request, and enter myself as surety therefor. ___________________________________________       Signature Street address             Name (please print; attorneys, include IC code #) City, State, Zip code             Telephone number Transcript due date 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 Section 19(h) of the Act provides that if the injured employee's disability has materially changed within 30 months after the decision or settlement contract (if it provides for installment payments, rather than a lump sum payment), either party may request a review by the Commission. 2 Section 8(a) of the Act provides for a review by the Commission if additional medical expenses are incurred. IC14 12/04 100 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