Free Adobe PDF - Illinois


File Size: 51.8 kB
Pages: 1
Date: October 11, 2005
File Format: PDF
State: Illinois
Category: Workers Compensation
Word Count: 111 Words, 1,164 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.iwcc.il.gov/ic17FORM.pdf

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ILLINOIS WORKERS' COMPENSATION COMMISSION MOTION TO VOLUNTARILY DISMISS

_____________________________________________
Employee/Petitioner

Case # ______ WC _______________

v. _____________________________________________
Employer/Respondent

I petition the Commission to enter an order to dismiss ________________________________________ , which is pending at arbitration ____ review ____ .

____________________________________________
Signature of petitioner

____________________________________________
Signature of attorney

____________________________________________
Name of petitioner (please print)

____________________________________________
Name of attorney (please print) IC attorney code#

_______________
Date

_______________
Date

O RDER

Pursuant to the above motion, the cause is hereby dismissed.

____________________________________________
Signature of arbitrator or commissioner

_______________
Date

IC17 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