Fillable ILLINOIS WORKERS COMPENSATION COMMISSION APPEARANCE OF REPRESENTATIVE (Illinois)

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ILLINOIS WORKERS COMPENSATION COMMISSION APPEARANCE OF REPRESENTATIVE (Illinois)

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ILLINOIS WORKERS’ COMPENSATION COMMISSION
APPEARANCE OF REPRESENTATIVE
Please see the other side of this form.
_________________________________________ Case # ______ WC _______________
Employee/Petitioner
v.
_________________________________________
Employer/Respondent
I hereby enter my appearance as counsel ___ co-counsel ___ for the petitioner ___ respondent ___ .
______________________________________________ ______________________________________________
Signature of attorney Firm's name
______________________________________________ ______________________________________________
Attorney's name and IC attorney code #
1
(please print) Street address
______________________________________________ ______________________________________________
Telephone number E-mail address City, State, Zip code
______________________________________________
Name of respondent's insurance/service company (please print)
ATTENTION, ATTORNEY. A co-counsel appearance must be accompanied by a copy of the original Attorney
Representation Agreement with the co-counsel's signature. Please indicate where the Commission should send
notices:
___ Name and address listed above ______________________________________________
______________________________________________
______________________________________________
PROOF OF SERVICE
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 _____________ 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 Commission assigns code numbers to attorneys who regularly appear before it. To obtain or look up a code number, contact the Information Unit in
the Chicago office or any of the downstate offices at the telephone numbers listed below.
IC6 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
AM
REJECTION OF APPEARANCE
Date ___________________________
To: __________________________________________________
__________________________________________________
__________________________________________________
Your appearance has been rejected for the following reason(s):
_____ No case number is listed.
_____ The wrong case number is listed.
_____ You did not attach the Attorney Representation Agreement. This is required for a petitioner's counsel.
_____ You did not provide a copy of the original Attorney Representation Agreement with your signature.
This is required for a petitioner's co-counsel.
_____ Proof of service was not provided.
_____ You did not indicate where notices should be sent.
_____ Another attorney is listed as counsel, and he or she has not withdrawn or been dismissed.
_____ Other: _____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
If you have questions, please contact any Commission office. Return the corrected form to:
DATA ENTRY UNIT
ILLINOIS WORKERS’ COMPENSATION COMMISSION
100 W. RANDOLPH STREET #8-200
CHICAGO, IL 60601
IC6 page 2
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ILLINOIS WORKERS COMPENSATION COMMISSION APPEARANCE OF REPRESENTATIVE (Illinois)

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Completed 11 May 2021

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