ILLINOIS WORKERS’ COMPENSATION COMMISSION SETTLEMENT CONTRACT LUMP SUM PETITION AND ORDER ATTENTION. Please type or print. Answer all questions. File four copies of this form. Attach a recent medical report. Workers' Compensation Act ___ Occupational Diseases Act ___ Fatal case? No ___ Yes ___ Date of death ____________________________________ ___________________ Case # Employee/Petitioner v. ____________________________________ Setting ______________________________ Employer/Respondent To resolve this dispute regarding the benefits due the petitioner under the Illinois Workers' Compensation or Occupational Diseases Act, we offer the following statements. We understand these statements are not binding if this contract is not approved. __________________________________________________________________________________________ Employee's name Street address City, State, Zip code __________________________________________________________________________________________ Employer's name Street address City, State, Zip code Male ____ Female ____ Married ____ Single ____ # Dependents under age 18 _____ Birthdate _______________ Average weekly wage $ _______________ Date of accident __________________ How did the accident occur? ____________________________________________________________________________________ What part of the body was affected? ______________________________________________________________________________ What is the nature of the injury? ________________________________________________________________________________ The employer was notified of the accident orally ____ in writing ____ . Return-to-work date __________________________ Location of accident ____________________________ Did the employee return to his or her regular job? Yes ___ No ___ If not, explain below and describe the type of work the employee is doing, the wage earned, and the current employer's name and address. TEMPORARY TOTAL DISABILITY BENEFITS: Compensation was paid for _________ weeks at the rate of $ _________ /week. The employee was temporarily totally disabled from ___________________________ through ___________________________ MEDICAL EXPENSES: The employer has ____ has not ____ paid all medical bills. List unpaid bills in the space below. PREVIOUS AGREEMENTS: Before the petitioner signed an Attorney Representation Agreement, the respondent or its agent offered in writing to pay the petitioner $ _________________ as compensation for the permanent disability caused by this injury. An arbitrator or commissioner of the Commission previously made an award on this case on TTD ______________ Permanent disability _____________ ____________________________ Medical expenses ____________ regarding Other ____________ IC5 11/11 100 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 TERMS OF SETTLEMENT: Attach a recent medical report signed by the physician who examined or treated the employee. Total amount of settlement $ _______________ Deduction: Attorney's fees $ _______________ Deduction: Medical reports, X-rays $ _______________ Deduction: Other (explain) $ _______________ Amount employee will receive $ _______________ PETITIONER'S SIGNATURE. Attention, petitioner. Do not sign this contract unless you understand all of the following statements. I have read this document, understand its terms, and sign this contract voluntarily. I believe it is in my best interests for the Commission to approve this contract. I understand that I can present this settlement contract to the Commission in person. I understand that by signing this contract, I am giving up the following rights: 1. My right to a trial before an arbitrator; 2. My right to appeal the arbitrator's decision to the Commission; 3. My right to any further medical treatment, at the employer's expense, for the results of this injury; 4. My right to any additional benefits if my condition worsens as a result of this injury. ______________________________________________________________________________________________________________ Signature of petitioner Name of petitioner (please print) Telephone number Date PETITIONER'S ATTORNEY. I attest that any fee petitions on file with the IWCC have been resolved. Based on the information reasonably available to me, I recommend this settlement contract be approved. R ESPONDENT'S ATTORNEY. I attest that any fee petitions on file with the IWCC have been resolved. The respondent agrees to this settlement and will pay the benefits to the petitioner or the petitioner's attorney, according to the terms of this contract, promptly after receiving a copy of the approved contract. _________________________________________________ _________________________________________________ Signature of attorney Signature of attorney or agent Date Date _________________________________________________ _________________________________________________ Attorney’s name and IC code # (please print) Attorney’s name and IC code # or agent (please print) _________________________________________________ _________________________________________________ Firm name Firm name _________________________________________________ _________________________________________________ Street address Street address _________________________________________________ _________________________________________________ City, State, Zip code City, State, Zip code _________________________________________________ _________________________________________________ Telephone number Telephone number E-mail address E-mail address _________________________________________________ Name of respondent's insurance or service company (please print) O RDER OF ARBITRATOR OR COMMISSIONER: Having carefully reviewed the terms of this contract, in accordance with Section 9 of the Act, by my stamp I hereby approve this contract, order the respondent to promptly pay in a lump sum the total amount of settlement stated above, and dismiss this case. 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