ILLINOIS WORKERS’ COMPENSATION COMMISSION
APPLICATION FOR ADJUSTMENT OF CLAIM (APPLICATION FOR BENEFITS)
ATTENTION. Please type or print. Answer all questions. File three copies of this form.
Workers' Compensation Act ___ Occupational Diseases Act ___ Fatal case? No ___ Yes ___ Date of death __________
_________________________________ Case #
Employee/Petitioner (Office use only)
v.
_________________________________ Location of accident ________________________
Employer/Respondent or last exposure City, State
______________________________________________________________________________________
Injured employee's name
1
Street address City, State, Zip code
______________________________________________________________________________________
Employer's name Street address City, State, Zip code
Employee information: State Employee? Yes ____ No ____ Male ____ Female ____ Married ____ Single ____
# Dependents under age 18 ______ Birthdate _____________ Average weekly wage $ _________________
Date of accident
2
_______________________ The employer was notified of the accident orally ____ in writing ____
How did the accident occur? ____________________________________________________________________________
What part of the body was affected? ______________________________________________________________________
What is the nature of the injury? ___________________________________ Return-to-work date
3
________________
Is a Petition for an Immediate Hearing attached? Yes ____ No ____
Is the injured employee currently receiving temporary total disability benefits? Yes ____ No ____
If a prior application was ever filed for this employee, list the case number and its status ______________________________
ATTENTION, PETITIONER. This is a legal document. Be sure all blanks are completed correctly and you understand the statements before
you sign this. Refer to the Commission's Handbook on Workers' Compensation and Occupational Diseases
4
for more information.
_________________________________________ __________________________
Signature of petitioner Date
APPEARANCE OF PETITIONER'S ATTORNEY
Please attach a copy of the Attorney Representation Agreement.
_________________________________________ ____________________________________________
Signature of attorney Street address
_________________________________________ ____________________________________________
Attorney’s name and IC code #
5
(please print) City, State, Zip code
_________________________________________ ___________________ _______________________
Firm name Telephone number E-mail address
IC1 5/12 100 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
