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ILLINOIS WORKERS' COMPENSATION COMMISSION RESPONSE TO PETITION FOR IMMEDIATE HEARING UNDER SECTION 19(b-1) OF THE ACT

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Employee/Petitioner

Case # ______ WC _______________

v.

_________________________________
Employer/Respondent

On _______________ , the respondent received the petitioner's Petition for an Immediate Hearing Under Section 19(b-1) of the Act . By law, the respondent must reply within 15 days of receipt. The respondent makes the following claims:
YES NO

The respondent was operating under the Act on the date of the alleged accident. The petitioner was an employee of the respondent on the date of the alleged accident or exposure. The alleged accident or disease arose out of and in the course of employment. The respondent indicates its agreement or disagreement with the petitioner's allegations regarding each of the following items: 1. 2. 3. 4. 5. 6. 7. 8. 9. Date, time, and location of the accident Description of the accident Nature of the injury Notice of the accident Employer's refusal to pay proper compensation and/or medical benefits, as claimed by petitioner Temporary Total Disability benefits The petitioner was treated by a medical provider selected by the employer. The respondent received a list of medical providers and dates of treatments. The parties tried but were unable to resolve this dispute.

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AGREE

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DISAGREE

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10. The respondent received the names and addresses of employee's witnesses and others testifying. 11. The respondent received a recent medical report stating the employee is unable to work. 12. The respondent received authorization to review the employee's related medical records. 13. The respondent received documents supporting the employee's allegations. 14. The respondent received a list of documents demanded by the employee's subpoena.

ATTENTION, RESPONDENT. You must submit the following items with this response: 15. Complete copies of all documents in the employer's possession that you will use to support this response; 16. A list of all documents you are demanding by subpoena; 17. A list of the names and addresses of witnesses and others you will use to support this response; 18. A list of the name and address of each medical provider selected by the employer to examine the employee pursuant to Section 12 of the Act, and the time and place of each exam.
IC14b 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

Explain each item of disagreement (include legal and factual issues):

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Signature of person completing form Date

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Street address

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Name (please print; attorneys, please include IC attorney code #)

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City, State, Zip code

P ROOF OF S ERVICE
If the person who signed the Proof of Service is not an attorney, this form must be notarized.

I, ___________________________ , affirm that I delivered _____ sent by certified mail (return receipt requested) _____ a copy of this form at ___________ AM on ___________________ to each party at the address(es) listed below.

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Signature of person completing Proof of Service

Signed and sworn to before me on ___________________

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Notary Public

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