Free IC28 - Illinois


File Size: 20.7 kB
Pages: 1
Date: October 11, 2005
File Format: PDF
State: Illinois
Category: Workers Compensation
Author: SPiha
Word Count: 94 Words, 915 Characters
Page Size: 612 x 793 pts
URL

http://www.iwcc.il.gov/ic28FORM.pdf

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ILLINOIS WORKERS' COMPENSATION COMMISSION MOTION TO WITHDRAW AS ATTORNEY OF RECORD

_______________________________________________
Employee/Petitioner v.

Case # ________ WC ____________________

_______________________________________________
Employer/Respondent

I, ______________________________________________ , attorney for the petitioner ____ respondent ____ , request permission to withdraw as the attorney of record on this case for the following reason:

_____________________________________________ Signature of attorney

_____________________________________________ Name of attorney and IC code number (please print)

_____________________________________________ Date

IC28 12/04 100 W. Randolph St. #8-200 Chicago, IL 60601 312/814-611 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