STATE OF ILLINOIS COUNTY OF ______________ ) ) ) ILLINOIS WORKERS’ COMPENSATION COMMISSION ORDER REMOVING SETTLED CASE FROM CALL Case # ______ WC _______________ _____________________________________________ Employee/Petitioner v. Date contract was approved ___________________ _____________________________________________ Employer/Respondent We attest that this case was settled and approved over 90 days ago; the case has not been removed from the call sheet, which lists open cases; and a copy of the settlement contract is not readily available. _____________________________________________________________________________________________________________ Signature of petitioner or petitioner’s attorney Name (please print) Note: If the person who signs this form is not an attorney, the form must be notarized. Date _____________________________________________________________________________________________________________ Signature of respondent’s attorney Name (please print) Date It is preferable that both parties sign above. However, if one party cannot be located, the other party must complete the appropriate section below. ❑ Petitioner attests that Respondent cannot be located. Petitioner tried to contact the party by ❑ phone ❑ mail ❑ email ❑ in person on the following dates: ❑ ______________________________________ Respondent attests that Petitioner cannot be located. Respondent tried to contact the party by ❑ phone ❑ mail ❑ email ❑ in person on the following dates: ______________________________________ ORDER I order that this case shall be removed from the call. _____________________________________________________________________________________________________________ Signature of arbitrator Name (please print) Date Every effort should be made to find a settlement contract. This form should be used only on those rare occasions when a contract cannot be located. IC34s 4/08 100 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