Free IC27 - Illinois


File Size: 18.8 kB
Pages: 1
Date: October 11, 2005
File Format: PDF
State: Illinois
Category: Workers Compensation
Author: SPiha
Word Count: 82 Words, 837 Characters
Page Size: 612 x 793 pts
URL

http://www.iwcc.il.gov/ic27FORM.pdf

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ILLINOIS WORKERS' COMPENSATION COMMISSION MOTION TO DISMISS ATTORNEY OF RECORD

_______________________________________________
Employee/Petitioner v.

Case # ________ WC ____________________

_______________________________________________
Employer/Respondent

The petitioner ____

respondent ____ requests the Commission to dismiss the attorney of record in this case,

_____________________________________________ , for the following reason:

_____________________________________________ Signature

_____________________________________________ Name (please print)

_____________________________ Date

IC27 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