ILLINOIS WORKERS' COMPENSATION COMMISSION NOTICE OF MOTION AND ORDER ATTENTION. You must attach the motion to this notice. If the motion is not attached, this form may not be processed. Upon filing of a motion before a Commissioner on review, the moving party is responsible for payment for preparation of the transcript. ______________________________________ Employee/Petitioner v. Case # _____ WC ___________ ______________________________________ Employer/Respondent TO: AM On _____________________ , at _______________ AM/PM , or as soon thereafter as possible, I shall appear before the Honorable __________________________________ , or any arbitrator or commissioner appearing in his or her place at ______________________________ , Illinois, and present the attached motion for: ___ Change of venue (#3072) ___ Fees ___ Fees under Section 16 (#1600) under Section 16a (#1645) ___ Reinstatement ___ Request of case (#3074) ___ Consolidation (list case#) of cases (#3071) for hearing (#R33) ___ Hearing under Sect.19(b) (#1902) under Sect. 19(k) (#1911) under Sect. 19(l) (#1912) ___ Withdrawal ___ Other of attorney (#3073) ___ Penalties ___ Dismissal ___ Dismissal (explain) of attorney of review (#3052) ___ Penalties _________________________________ (#3085) _____________________________________ Signature _____________________________________ Street address Petitioner ____ Respondent ____ _____________________________________ Attorney's name and IC code # (please print) 1 _____________________________________ City, State, Zip code _____________________________________ Name of law firm, if applicable _____________________________________ Telephone number E-mail address ORDER The motion is set for hearing on ___________________________________ _____________________________________ Signature of arbitrator or commissioner _____________________________________ Date ORDER The motion is ___ Granted ___ Denied Signature of arbitrator or commissioner ___ Withdrawn ___ Dismissed ___ Continued to ________________ ___ Set for trial (date certain) on ________________ _____________________________________ Date _____________________________________ IC4 4/11 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free line 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. I, ________________________________ , affirm that I delivered _____ mailed with proper postage _____ in the city of _________________________________ a copy of this form at ___________ on ___________________ to each party at the address(es) listed below. _____________________________________________ Signature of person completing Proof of Service Signed and sworn to before me on _____________________ _____________________________________________ Notary Public 1 The Workers' Compensation 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. IC4 page 2 American LegalNet, Inc. www.FormsWorkFlow.com