ILLINOIS WORKERS' COMPENSATION COMMISSION PETITION FOR RECONSIDERATION OF APPLICATION FOR SELF-INSURANCE Initial Application Renewal Application The employer, ______________________________________________________ , petitions the chairman of the Commission to reconsider the conditional approval or denial of the Application for Self-Insurance for the following reasons. You must state the reasons why the chairman should reconsider the determination, provide documents in support of your position, and, if applicable, any information not previously considered. Attach additional pages, if necessary. In support of the above statements, the employer attaches the following documents: You may request a hearing on this petition by checking the box below. In the absence of a request for a hearing, the chairman will make a determination based upon a review of the petition and the accompanying documentation. A hearing on this Petition for Reconsideration is requested. ______________________________________ Signature of representative and Date _________________________________________ Street address ______________________________________ Name of representative (please print) _________________________________________ City, State, Zip code ______________________________________ Name of employer _________________________________________ Telephone number Fax number ________________________________________________ Email address 50 Illinois Administrative Code 7100.70(f), (g), and (h) appears on the other side. IC51 4/12 Illinois Workers' Compensation Commission-Office of Self-Insurance Administration 4500 S. Sixth S. Frontage Road, Springfield, IL 62703 217/785-7084 American LegalNet, Inc. www.FormsWorkFlow.com Rules Governing Practice Before the Commission 50 Illinois Administrative Code Chapter II, Section 7100.70 (f), (g), and (h) Section 7100.70 Requirements for Approval as a Self-insurer f) Petition for Reconsideration 1) Within 21 days after receipt of a notice of conditional approval or a notice that the employer's initial or renewal application does not warrant approval of the self-insurance privilege, the employer may file a petition for reconsideration of the Chairman's determination. 2) The petition for reconsideration shall be made in writing and must state the reasons why the Chairman should reconsider the decision. 3) The petition shall be accompanied by any documents which support the employer's position, and, if applicable, any information not previously considered. Such information may include, but is not limited to, evidence of an improving financial condition which was not available to the Board when the application was reviewed. 4) Request for Hearing A) The employer may request a hearing on the petition for reconsideration. The request for hearing must be filed with the request for reconsideration. B) Upon the filing of a timely petition for reconsideration and request for hearing as defined in subsection (f)(1) above, the Chairman shall issue a notice which sets forth a place and time of hearing within 30 days after the date of the notice. C) Hearings on the petition for reconsideration shall be conducted in accordance with subsection (g) below. D) In the absence of a request for hearing, the Chairman may consider all matters at issue from the petition for reconsideration and accompanying documentation. 5) The Chairman shall issue an order notifying the employer of his final decision and the reasons therefor. Such order shall be subject to review pursuant to subsection (h) below. g) Conduct of Hearings 1) All hearings under this Section shall be conducted by the Chairman or Commissioner designated by the Chairman. 2) All hearings shall be conducted in accordance with the requirements of Article 10 of the Administrative Procedure Act [5 ILCS 100/Art. 10] . 3) At the hearing, the employer shall have the right to respond and to call witnesses, cross-examine witnesses and present evidence. 4) The Commission, or any member thereof, shall have the power to administer oaths, to subpoena and examine witnesses and issue subpoena duces tecum requiring the production of such books, papers, records or documents as may be evidence to determine the issues of denial or termination of the selfinsurance privilege or adjustment of the security. [820 ILCS 305/16] 5) The Illinois common law rules of evidence and Article VIII of the Code of Civil Procedure [35 ILCS 5/Art. VIII] shall apply at the hearing. h) Appeal All orders made by the Chairman under Section 4(j) of the Act shall be subject to review in the same manner and within the same time as provided by subsection (f) of Section 19 of the Act for review of awards and decisions of the Commission. (Section 4(j) of the Act) (Source: Amended at 20 Ill. Reg. 3826, effective February 15, 1996) American LegalNet, Inc. www.FormsWorkFlow.com