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 __________ _________________________________ Employee/Petitioner Case # (Office use only) v. _________________________________ Employer/Respondent Location of accident ________________________ or last exposure City, State ______________________________________________________________________________________ Injured employee's name 1 Street address City, State, Zip code ______________________________________________________________________________________ Employer's name Street address City, State, Zip code Employee information: State Employee? Yes ____ No ____ # Dependents under age 18 ______ Male ____ Female ____ Married ____ Single ____ Birthdate _____________ Average weekly wage $ _________________ Date of accident 2 _______________________ 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 ____ Yes ____ No ____ Return-to-work date 3 ________________ Is the injured employee currently receiving temporary total disability benefits? 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 __________________________ Date APPEARANCE OF PETITIONER'S ATTORNEY Please attach a copy of the Attorney Representation Agreement. _________________________________________ Signature of attorney ____________________________________________ Street address _________________________________________ Attorney's name and IC code # (please print) 5 ____________________________________________ City, State, Zip code _________________________________________ Firm name ___________________ _______________________ Telephone number E-mail address IC1 5/12 100 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 American LegalNet, Inc. www.FormsWorkFlow.com PROOF OF SERVICE 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 _____ in the city of _________________________________ a copy of this form at ___________ AM mailed with proper postage _____ 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 ________________ ___________________________________________ Notary Public 1 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. 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. 2 3 4 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 5 American LegalNet, Inc. www.FormsWorkFlow.com