ILLINOIS WORKERS' COMPENSATION COMMISSION PETITION FOR AN IMMEDIATE HEARING UNDER SECTION 19(b) OF THE ACT
Complete both sides of this form.
Case # ________ WC ____________________
I, the petitioner, request an immediate hearing in this matter. I am unable to return to work at this time because of the injuries or disability caused by my employment, and I am not receiving temporary total disability benefits or medical benefits. I further provide the following information: 1. Date, time, and location of accident Description of accident Nature of injury
2. 3. 4. 5. 6. 7.
Notice of the accident was given orally ___ in writing ___ to ________________________ on ___________________ . The employer has refused to pay proper compensation ___ I did ___ medical benefits ___ .
did not ___ receive medical treatment for the accident from a medical provider selected by the employer. __________________________________________________________________
Name and address of medical provider(s), and dates of treatments:
__________________________________________________________________________________________________ 8. Are any medical bills in dispute? If so, please list. _________________________________________________________ __________________________________________________________________________________________________ 9. On ____________________ , I gave the employer (list name and job title) ________________________________________ the following information stating I am unable to return to work: A recent statement, signed by a medical provider ____ Other (explain) ____________________________________________________________________________________ 10. When was the last payment of temporary total disability benefits, if any? ______________________________________ 11. In an attempt to resolve the disputed matters, _____________________________________________________________
Petitioner or petitioner's attorney (please print)
conferred with _____________________________________________________ by telephone ___
Respondent or respondent's representative
in person ___
on _________________________ , but they were unable to resolve this dispute.
____________________________________________________ Signature of petitioner or petitioner's attorney ____________________________ Date _____________________________ Telephone number
ATTENTION, RESPONDENT. According to Commission Rules, you must file a Response to the Petition for an Immediate Hearing within 15 days from the date this petition was served on you. If you fail to respond in good faith, attorney's fees or penalties may be levied against you.
IC7 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
P ROOF OF S ERVICE
If the person who signed the Proof of Service is not an attorney, this form must be notarized. This form must be served on the arbitrator and other parties 15 days before the status call.
I, ________________________________ , affirm that I delivered _____ mailed with proper postage _____ in the city of _________________________________ a copy of this form at ___________ AM on ___________________ to each party at the address(es) listed below.
Signature of person completing Proof of Service
Signed and sworn to before me on __________________
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