STATE OF ILLINOIS ) )SS. Injured Workers' Benefit Fund (�4(d)) Rate Adjustment Fund (�8(g)) Second Injury Fund (�8(e)18) None of the above COUNTY OF ) ILLINOIS WORKERS' COMPENSATION COMMISSION ARBITRATION DECISION Case # Employee/Petitioner WC v. Employer/Respondent Consolidated cases: An Application for Adjustment of Claim was filed in this matter, and a Notice of Hearing was mailed to each party. The matter was heard by the Honorable , Arbitrator of the Commission, in the city of , on . After reviewing all of the evidence presented, the Arbitrator hereby makes findings on the disputed issues checked below, and attaches those findings to this document. DISPUTED ISSUES A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. Was Respondent operating under and subject to the Illinois Workers' Compensation or Occupational Diseases Act? Was there an employee-employer relationship? Did an accident occur that arose out of and in the course of Petitioner's employment by Respondent? What was the date of the accident? Was timely notice of the accident given to Respondent? Is Petitioner's current condition of ill-being causally related to the injury? What were Petitioner's earnings? What was Petitioner's age at the time of the accident? What was Petitioner's marital status at the time of the accident? Were the medical services that were provided to Petitioner reasonable and necessary? Has Respondent paid all appropriate charges for all reasonable and necessary medical services? What temporary benefits are in dispute? TPD Maintenance TTD What is the nature and extent of the injury? Should penalties or fees be imposed upon Respondent? Is Respondent due any credit? Other ICArbDec 2/10 100 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 FINDINGS On , Respondent operating under and subject to the provisions of the Act. exist between Petitioner and Respondent. On this date, an employee-employer relationship On this date, Petitioner Timely notice of this accident sustain an accident that arose out of and in the course of employment. given to Respondent. causally related to the accident. ; the average weekly wage was $ with children under 18. . Petitioner's current condition of ill-being In the year preceding the injury, Petitioner earned $ On the date of accident, Petitioner was Petitioner years of age, received all reasonable and necessary medical services. Respondent has paid all appropriate charges for all reasonable and necessary medical services. Respondent shall be given a credit of $ for TTD, $ $ for other benefits, for a total credit of $ . Respondent is entitled to a credit of $ ORDER for TPD, $ for maintenance, and under Section 8(j) of the Act. RULES REGARDING APPEALS Unless a party files a Petition for Review within 30 days after receipt of this decision, and perfects a review in accordance with the Act and Rules, then this decision shall be entered as the decision of the Commission. STATEMENT OF INTEREST RATE If the Commission reviews this award, interest at the rate set forth on the Notice of Decision of Arbitrator shall accrue from the date listed below to the day before the date of payment; however, if an employee's appeal results in either no change or a decrease in this award, interest shall not accrue. __________________________________________________ Signature of Arbitrator Date ICArbDec p. 2 American LegalNet, Inc. www.FormsWorkFlow.com