STATE OF ILLINOIS Injured Workers’ Benefit Fund (§4(d)) )SS. COUNTY OF ) Rate Adjustment Fund (§8(g)) ) Second Injury Fund (§8(e)18) None of the above ILLINOIS WORKERS’ COMPENSATION COMMISSION ARBITRATION DECISION FATAL Case # WC Employee/Petitioner Consolidated cases: v. Employer/Respondent 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. Was Respondent operating under and subject to the Illinois Workers' Compensation or Occupational Diseases Act? B. Was there an employee-employer relationship? C. Did an accident occur that arose out of and in the course of Decedent's employment by Respondent? D. What was the date of the accident? E. Was timely notice of the accident given to Respondent? F. Is Decedent's current condition of ill-being causally related to the injury? G. What were Decedent's earnings? H. What was Decedent's age at the time of the accident? I. What was Decedent's marital status at the time of the accident? J. Who was dependent on Decedent at the time of death? K. Were the medical services that were provided to Decedent reasonable and necessary? Has Respondent paid all appropriate charges for all reasonable and necessary medical services? L. What compensation for permanent disability, if any, is due? M. Should penalties or fees be imposed upon Respondent? N. Is Respondent due any credit? O. Other ICArbDecFatal 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 the date of accident, , Respondent was operating under and subject to the provisions of the Act. On this date, an employee-employer relationship did On this date, Decedent did sustain an accident that arose out of and in the course of employment. Timely notice of this accident was Decedent's death is given to Respondent. causally related to the accident. In the year preceding the injury, Decedent earned $ On the date of accident, Decedent was Respondent has exist between Decedent and Respondent. ; the average weekly wage was $ years of age, single . with children under 18. paid all reasonable and necessary 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 $ The Arbitrator finds that Decedent died on the Act, including . for TPD, $ for maintenance, and under Section 8(j) of the Act. , leaving survivor(s), as provided in Section 7(a) of ORDER Insert appropriate order text here. You may use and modify the appropriate text from the list of boilerplate paragraphs at http://www.iwcc.il.gov/arbordertext.doc [or use attached form: Arbitration Decision Order Paragraphs] 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 ICArbDecFatal p. 2 American LegalNet, Inc. www.FormsWorkFlow.com THIS IS A REPRESENTATION OF IWCC'S MS WORD FORM (directions are for MS Word form-modification only) ARBITRATION DECISION ORDER PARAGRAPHS FEBRUARY 2010 Note: This document has been protected to allow users to tab through fields, use drop-down menus, and enter information in blank fields. If you want to modify the text itself, go to Developer/Unprotect Document. Password = iwcc For more information on modifying forms, go to the Microsoft website: http://office.microsoft.com/en-us/word/HA100307461033.aspx?pid=CH100991571033#1 . Instructions These templates address the most common scenarios. Use only sentences that apply. Modify the language as necessary. For example, if no TTD is awarded, don’t use the sentence awarding TTD. Do not include the TTD sentence with zeroes in the fields. Similarly, if there are no children in a fatal case, don’t use the sentence, “Respondent shall make payments for not less than six years to any eligible child…” Credits Respondent shall be given a credit of $ benefits, for a total credit of $ . for TTD, $ for TPD, and $ for maintenance Respondent shall be given a credit of $ for medical benefits that have been paid, and Respondent shall hold petitioner harmless from any claims by any providers of the services for which Respondent is receiving this credit, as provided in Section 8(j) of the Act. Respondent shall be given credit for $ for benefits paid under Section of the Act. Denial of benefits Note: If benefits are denied, the findings section should indicate the basis for the denials, e.g., “an employeeemployer relationship did not exist...” No benefits are awarded. Maintenance Respondent shall pay Petitioner maintenance benefits of $ through , as provided in Section 8(a) of the Act. /week for weeks, commencing Temporary Partial Disability Respondent shall pay Petitioner temporary partial disability benefits of $ commencing through , as provided in Section 8(a) of the Act. /week for weeks, Temporary Total Disability Respondent shall pay Petitioner temporary total disability benefits of $ /week for commencing through , as provided in Section 8(b) of the Act. Respondent shall pay Petitioner the temporary total disability benefits that have accrued from , and shall pay the remainder of the award, if any, in weekly payments. Respondent shall be given a credit of $ weeks, through for temporary total disability benefits that have been paid. 1 American LegalNet, Inc. www.FormsWorkFlow.com Medical benefits Respondent shall pay reasonable and necessary medical services of $ Act. , as provided in Section 8(a) of the Respondent shall pay reasonable and necessary medical services of $ Act, subject to the fee schedule. , as provided in Section 8(a) of the Respondent shall be given a credit of $ for medical benefits that have been paid, and Respondent shall hold petitioner harmless from any claims by any providers of the services for which Respondent is receiving this credit, as provided in Section 8(j) of the Act. Permanent Partial Disability: Schedule injury Respondent shall pay Petitioner permanent partial disability benefits of $ /week for weeks, because the injuries sustained caused the % loss of the , as provided in Section 8(e) of the Act. Permanent Partial Disability: Person as a whole Note: If awarding both 8(e) and 8(d)2 benefits, list each benefit in a separate sentence. Do not combine benefit amounts. Respondent shall pay Petitioner permanent partial disability benefits of $ /week for weeks, because the injuries sustained caused the % loss of the person as a whole, as provided in Section 8(d)2 of the Act. Permanent Partial Disability: Wage differential Respondent shall pay Petitioner permanent partial disability benefits, commencing , of $ /week for the duration of the disability, because the injuries sustained caused a loss of earnings, as provided in Section 8(d)1 of the Act. Permanent Partial Disability: Disfigurement Respondent shall pay Petitioner permanent partial disability benefits of $ /week for weeks, because the injuries sustained caused the disfigurement of the , as provided in Section 8(c) of the Act. Permanent Total Disability Respondent shall pay Petitioner permanent and total disability benefits of $ , as provided in Section 8(f) of the Act. /week for life, commencing Commencing on the second July 15th after the entry of this award, Petitioner may become eligible for cost-ofliving adjustments, paid by the Rate Adjustment Fund , as provided in Section 8(g) of the Act. Permanent Total Disability (Statutory) language Respondent shall pay Petitioner statutory permanent and total disability benefits of $ /week for life, commencing , because the injury caused 100% loss of the right arm and 100% loss of the right arm , as provided in Section 8(e)18 of the Act, Commencing on the second July 15th after the entry of this award, Petitioner may become eligible for cost-ofliving adjustments, paid by the Rate Adjustment Fund , as provided in Section 8(g) of the Act. 2 American LegalNet, Inc. www.FormsWorkFlow.com Permanent Total Disability (Statutory)/Second Injury Fund Because Petitioner had previously sustained 100% loss of the right arm and, as a result of this accident, has sustained 100% loss of the right arm , Petitioner is eligible for statutory permanent total disability benefits of $ /week for life, commencing , as provided in Section 8(e)18 of the Act. Respondent shall pay Petitioner $ /week for weeks, commencing , for the loss of the second body part and, during this time, the Second Injury Fund shall pay Petitioner $ /week for weeks, to equal the total PTD rate, as provided in Section 8(f) of the Act. Commencing , the Second Injury Fund shall pay Petitioner $ /week for life. Commencing on the second July 15th after the entry of this award, Petitioner may become eligible for cost-ofliving adjustments, paid by the Rate Adjustment Fund , as provided in Section 8(g) of the Act. Fatal Respondent shall pay death benefits, commencing , of $ /week to the surviving spouse, [name], on his or her own behalf and on behalf of the children: [child's name], born [child's birthdate]; [child's name], born [child's birthdate]; [child's name], born [child's birthdate]; and $ /week to , natural parent and guardian of the minor child(ren) of the decedent: [child's name], born [child's birthdate]; [child's name], born [child's birthdate]; [child's name], born [child's birthdate]; [child's name], born [child's birthdate], until $250,000 has been paid or 20 years, whichever is greater, have been paid, because the injury caused the employee’s death, as provided in Section 7 of the Act. If the surviving spouse dies before the maximum benefit level has been reached, and the children herein named still survive, Respondent shall continue to pay benefits until the youngest child reaches 18 years of age; however, if such child is enrolled as a full-time student in an accredited educational institution, payments shall continue until the child reaches 25 years of age. If any child is physically or mentally incapacitated, payments shall continue for the duration of the incapacity. If no children named herein are alive upon the death of the surviving spouse, payments shall cease. If the surviving spouse remarries, and no children remain eligible, Respondent shall pay the surviving spouse a lump sum equal to two years of compensation benefits; all further rights of the surviving spouse shall be extinguished. Respondent shall make payments for not less than six years to any eligible child under 18 years of age at the time of death. Respondent shall pay $4,200 for burial expenses to the surviving spouse or the person(s) incurring the burial expenses, as provided in Section 7(f) of the Act. Commencing on the second July 15th after the entry of this award, Petitioner may become eligible for cost-ofliving adjustments, paid by the Rate Adjustment Fund , as provided in Section 8(g) of the Act. Penalties Respondent shall pay to Petitioner penalties of $ , as provided in Section 16 of the Act; $ provided in Section 19(k) of the Act; and $ , as provided in Section 19(l) of the Act. 3 , as American LegalNet, Inc. www.FormsWorkFlow.com Short decision form Because the parties did not request a decision with findings of fact and conclusions of law, the Arbitrator is issuing a short decision form, pursuant to Section 19(b) of the Act. Injured Workers’ Benefit Fund The Illinois State Treasurer as ex-officio custodian of the Injured Workers’ Benefit Fund was named as a coRespondent in this matter. The Treasurer was represented by the Illinois Attorney General. This award is hereby entered against the Fund to the extent permitted and allowed under §4(d) of the Act, in the event of the failure of Respondent-Employer to pay the benefits due and owing the Petitioner. Respondent-Employer shall reimburse the Injured Workers' Benefit Fund for any compensation obligations of Respondent-Employer that are paid to the Petitioner from the Injured Workers' Benefit Fund. 4 American LegalNet, Inc. www.FormsWorkFlow.com