IL L INOIS WOR KER S C OM PENSA TION COMM ISSION APPE AR A NC E OF R EPR E SENTAT IVE Please see the other side of this form. _________________________________________ Case # ______ WC _______________ Employee/Petitioner v. _________________________________________ Employer/Respondent I hereby enter my appearance as counsel ___ co-counsel ___ for the petitioner ___ respondent ___ . ______________________________________________ ______________________________________________ Signature of attorney Firms name ______________________________________________ ______________________________________________ 1 Attorneys name and IC attorney code # (please print) Street address ______________________________________________ ______________________________________________ Telephone number E-mail address City, State, Zip code ______________________________________________ Name of respondents insurance/service company (please print) ATTENTION, ATTORNEY. A co-counsel appearance must be accompanied by a copy of the original Attorney Representation Agreement with the co-counsels signature. Please indicate where the Commission should send notices: ___ Name and address listed above ______________________________________________ ______________________________________________ ______________________________________________ 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 be low. ____________________________________________ Signature of person completing Proof of Service Signed and sworn to before me on __________________ ______________________________________________ Notary Public 1 The Commission assigns code numbers to attorneys who regularly appear before it. To obtain or look up a code number, contact the Information Unit in the Chicago office or any of the downstate offices at the telephone numbers listed below. IC6 12/04 100 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.USCourtForms.com>>>> 2 REJECTION OF APPEARANCE Date ___________________________ To: __________________________________________________ __________________________________________________ __________________________________________________ Your appearance has been rejected for the following reason(s): _____ No case number is listed. _____ The wrong case number is listed. _____ You did not attach the Attorney Representation Agreement. This is required for a petitioners counsel. _____ You did not provide a copy of the original Attorney Representation Agreement with your signature. This irse quired for a petitioners cco-ounsel. _____ Proof of service was not provided. _____ You did not indicate where notices should be sent. _____ A nother attorney is listed as counsel, and he or she has not withdrawn or been dismissed. _____ Other: _____________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ If you have questions, please contact any Commission office. Return the corrected form to: DATA ENTRY UNIT ILLINOIS WORKERS COMPENSATION COMMISSION 100 W. RANDOLPH STREET #8-200 CHICAGO, IL 60601 IC6 page 2 American LegalNet, Inc. www.USCourtForms.com