STATE OF ILLINOIS ) Injured Workers’ Benefit Fund (§4(d)) ) Rate Adjustment Fund (§8(g)) COUNTY OF ______________ ) Second Injury Fund (§8(e)18) None of the above ILLINOIS WORKERS’ COMPENSATION COMMISSION ARBITRATION DECISION REGARDING A FATAL CLAIM ________________________________________ Case # ______ WC _______________ Employee/Petitioner v. ________________________________________ Employer/Respondent An Application for Adjustment of Claim was filed in this matter, and a Notice of Hearing was mailed to each party. The matter was heard by the Honorable ______________________________________ , arbitrator of the Commission, in the city of ____________________________________ , on ____________________ . After reviewing all of the evidence presented, the arbitrator hereby makes findings on the disputed issues checked below, and attaches those findings to this document. DISPUTED ISSUES A. Was the respondent operating under and subject to the Illinois Workers' Compensation or Occupational Diseases Act? B. Was there an employee-employer relationship? C. Did an accident occur that arose out of and in the course of the decedent's employment by the respondent? D. What was the date of the accident? E. Was timely notice of the accident given to the respondent? F. What were the decedent's earnings? G. What was the decedent's age at the time of the accident? H. What was the decedent's marital status at the time of the accident? I. Who was dependent on the decedent at the time of death? J. Were the medical services that were provided to the decedent reasonable and necessary? K. What amount of compensation is due for temporary total disability? L. Should penalties or fees be imposed upon the respondent? M. Is the respondent due any credit? N. Other __________________________________________________________________ FINDINGS • On ___________________ , the respondent ________________________________ subject to the provisions of the Act. • On this date, an employee-employer relationship did • On this date, the decedent did • Timely notice of this accident was was operating under and exist between the decedent and respondent. sustain accidental injuries that arose out of and in the course of employment. given to the respondent. ICArbDecFatal 6/08 100 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 • In the year preceding the injury, the decedent earned $ _____________ , and the average weekly wage was $ ___________ . • At the time of injury, the decedent was _____ years of age, single • Necessary medical services • To date, $ __________________ has been paid by the respondent for death, TTD, and/or maintenance benefits. • The arbitrator finds that the decedent died on _________________ , leaving _____ survivor(s), as provided in Section 7(a) have with _____ children under 18. been provided by the respondent. of the Act, including ____________________________________________________________________________________________ . ORDER • The respondent shall pay the sum of $ _______________ /week to the surviving spouse on his or her own behalf and on behalf of the children named herein, until $250,000 has been paid or until 20 years have passed , whichever is greater. • The respondent shall pay the sum of $ ____________ /week to the natural parent and guardian of ___________________ , minor child(ren) of the decedent; these payments shall be used solely for the child(ren)'s care, education, and maintenance . • The respondent shall pay $ _______________ /week to _______________________________________________ . • To date, $ ____________________ has been paid for death, TTD, and/or maintenance benefits. • The respondent shall pay compensation that has accrued from ___________________ through __________________ , and shall pay the remainder of the award, if any, in weekly payments. • The respondent shall pay $ _____________ in penalties, as provided in Section 19(k) of the Act. • The respondent shall pay $ _____________ in penalties, as provided in Section 19(l) of the Act. • The respondent shall pay $ _____________ in penalties, as provided in Section ____ of the Act. • ______________________________ shall pay the sum of $ _________________ to ___________________________ for legal services provided to _____________________________________ . • If the surviving spouse dies before $250,000 or 20 years of weekly benefits , whichever is greater, have been paid, and the children herein named still survive, these payments shall continue until the youngest child reaches 18 years of age; however, if such child is enrolled as a full-time student in an accredited educational institution, payments shall continue until the child reaches 25 years of age. If any child is physically or mentally incapacitated, payments shall continue for the duration of the incapacity. If no children named herein are alive upon the death of the surviving spouse, payments shall cease. • If the surviving spouse remarries, and no children named herein survive, the respondent shall pay the surviving spouse a lump sum equal to two years of compensation benefits; all further rights of the surviving spouse shall be extinguished. • Payments to any eligible child under 18 years of age shall continue for not less than six years. • The respondent shall pay $4,200 for burial expenses to the surviving spouse or the person incurring the burial expenses. Unless a party files a Petition for Review within 30 days after receipt of this decision, and perfects a review in accordance with the Act and Rules, then this decision shall be entered as the decision of the Commission. RULES REGARDING APPEALS If the Commission reviews this award, interest at the rate set forth on the Notice of Decision of Arbitrator shall accrue from the date listed below to the day before the date of payment; however, if an employee's appeal results in either no change or a decrease in this award, interest shall not accrue. STATEMENT OF INTEREST RATE ________________________________________ ICArbDecFatal p. 2 _________________________ Signature of arbitrator Date American LegalNet, Inc. www.FormsWorkflow.com