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 __________
(Office use only)
Location of accident ________________________ or last exposure City, State
Injured employee's name
City, State, Zip code
Employer's name Street address City, State, Zip code
Employee information: Social Security # _________________ # Dependents under age 18 ______ Date of accident 2 _____________________
Male ____ Female ____
Married ____ Single ____
Average weekly wage $ ______________
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? ___________________________________ Is a Petition for an Immediate Hearing attached? Yes ____ No ____ Is the injured employee currently receiving temporary total disability benefits? Yes ____ No ____ Return-to-work date 3 ________________
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
A PPEARANCE OF P ETITIONER 'S A TTORNEY Please attach a copy of the Attorney Representation Agreement. _________________________________________
Signature of attorney
Attorney's name and IC code # (please print)
City, State, Zip code
IC1 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 Disclosure of this information to the Commission is done voluntarily under 820 ILCS 305/6(b).
P ROOF OF S ERVICE
If the person who signed the Proof of Service is not an attorney, this form must be notarized. If you prefer, you may submit the front of this application form with the Proof of Service on a separate page.
I, ________________________________ , affirm that I delivered _____ mailed with proper postage _____ in the city of _________________________________ a copy of this form at ___________ AM on ___________________ to the respondent listed on this application and to each
additional party, if any, at the address listed below.
Signature of person completing Proof of Service
Signed and sworn to before me on __________________
In most cases, the injured employee files this application and is referred to as the petitioner. If the injury was fatal, or if the worker is a minor or incapacitated, another person (as allowed by law) may file. In those cases, the person filing the application is the petitioner, and the worker is referred to as the injured employee. Please complete information related to age, etc., for the injured employee.
2 3 4
This may be the date of the accident, last exposure, disability, or death. If the employee has not returned to work, leave this space blank.
The Commission publishes a handbook that explains the workers' compensation system. If you would like a copy, please call any of the Commission offices listed on the other side of this form.
The Commission assigns code numbers to attorneys who regularly practice before it. To obtain or look up a code number, contact the Information Unit in Chicago or any of the downstate offices at the telephone numbers listed on this form.
IC1 page 2