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ILLINOIS WORKERS COMPENSATION COMMISSION REQUEST FOR HEARING (Illinois)

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ILLINOIS WORKERS’ COMPENSATION COMMISSION
REQUEST FOR HEARING
ATTENTION. 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. STENOGRAPHIC 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
NOTE: The arbitration decision will be sent by certified mail to the addresses listed above.
IC9 p. 2
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ILLINOIS WORKERS COMPENSATION COMMISSION REQUEST FOR HEARING (Illinois)

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Completed 23 March 2021

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