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ILLINOIS WORKERS' COMPENSATION COMMISSION APPEARANCE OF REPRESENTATIVE
Please see the other side of this form.

_________________________________________
Employee/Petitioner

Case # ______ WC _______________

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 _____ in the city of _________________________________ a copy of this form at _____________ AM

mailed with proper postage _____

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

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
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