STATE OF ILLINOIS ) Injured Workers’ Benefit Fund (§4(d)) ) COUNTY OF Rate Adjustment Fund (§8(g)) ) Second Injury Fund (§8(e)18) None of the above ILLINOIS WORKERS’ COMPENSATION COMMISSION 19(b-1) ARBITRATION DECISION ___________________________________ 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 petitioner filed a Petition for an Immediate Hearing Under Section 19(b-1) of the Act on ___________________ . The respondent filed a Response on ______________ . 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 petitioner'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. Is the petitioner's present condition of ill-being causally related to the injury? G. What were the petitioner's earnings? H. What was the petitioner's age at the time of the accident? I. What was the petitioner's marital status at the time of the accident? J. Were the medical services that were provided to petitioner 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 ___________________________________________________________________________________ ICArbDec19(b-1) 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 FINDINGS was • On _________________ , the respondent ________________________________________ operating under and subject to the provisions of the Act. • On this date, an employee-employer relationship • On this date, the petitioner • Timely notice of this accident • In the year preceding the injury, the petitioner earned $ __________ ; the average weekly wage was $ _______ . • At the time of injury, the petitioner was _____ years of age, single • Necessary medical services have • To date, $ _____________ has been paid by the respondent for TTD and/or maintenance benefits. did was did exist between the petitioner and respondent. sustain injuries that arose out of and in the course of employment. given to the respondent. with _____ children under 18. been provided by the respondent. ORDER • The respondent shall pay the petitioner temporary total disability benefits of $ _______________ /week for _______ weeks, from ____________ through ___________ , as provided in Section 8(b) of the Act, because the injuries sustained caused the disabling condition of the petitioner, the disabling condition is temporary and has not yet reached a permanent condition, pursuant to Section 19(b-1) of the Act. • The respondent shall pay $ _____________ for medical services, as provided in Section 8(a) of the Act. • 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 attorneys’ fees, as provided in Section 16 of the Act. • In no instance shall this award be a bar to subsequent hearing and determination of an additional amount of temporary total disability, medical benefits, or compensation for a permanent disability, if any. Unless a party 1) files a Petition for Review within 30 days after receipt of this decision; and 2) certifies that he or she has paid the court reporter $ __________ for the final cost of the arbitration transcript and attaches a copy of the check to the Petition; and 3) 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 ________________________________________ _________________________ Signature of arbitrator Date ICArbDec19(b-1) p. 2 American LegalNet, Inc. www.FormsWorkflow.com