(Rev. 11/01/04) CCL 0038 2838 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, LAW DIVISION _________________________________________________ v. Illinois Workers’ Compensation Commission of Illinois and _________________________________________________ } No. _____________________________ CERTIFICATE OF MAILING WORKER’S COMPENSATION On _________________________________________, ________, I mailed a copy of the summons to the Illinois Workers’ Compensation Commission of Illinois, 100 West Randolph Street, Chicago, Illinois, and on the same date I mailed copies to the parties and attorneys at the address as follows: Parties in interest Attorneys of record Dated: ____________________________, ________ ________________________________________ DOROTHY BROWN, Clerk of the Circuit Court DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form