ILLINOIS WORKERS’ COMPENSATION COMMISSION INJURED WORKERS’ BENEFIT FUND: REQUEST FOR BENEFITS AND AFFIDAVIT _________________________________ Case # ____ WC ___________ Employee/Petitioner v. _________________________________ Employer/Respondent I, _____________________________________________________ , duly swear: Petitioner’s name The Injured Workers’ Benefit Fund was joined with the employer as a respondent in this case. On _______________ , the Commission awarded $ ____________________ in benefits (excluding penalties and attorneys’ fees). A copy of that document is attached. The employer/respondent failed to obtain workers’ compensation insurance coverage for this case. I now ask the Commission to pay the benefits due from the Injured Workers’ Benefit Fund. Benefits paid to date by employer $ ____________________ Unpaid benefits $ ____________________ I understand that by accepting this compensation from the Illinois Workers’ Benefit Fund, I will not receive any further monetary award from the Illinois Workers’ Benefit Fund for this case. _______________________________________________________ ________________________ Petitioner’s signature Date _______________________________________________________ ________________________ Petitioner’s mailing address Social Security Number (required) Subscribed and sworn to before me on ___________________________ _________________________________ Notary Public IC44 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