STATE OF ILLINOIS ) Injured Workers’ Benefit Fund (§4(d)) ) Rate Adjustment Fund (§8(g)) COUNTY OF ______________ ) Second Injury Fund (§8(e)18) None of the above ILLINOIS WORKERS’ COMPENSATION COMMISSION ARBITRATION DECISION REGARDING THE NATURE AND EXTENT OF THE INJURY _____________________________________ Case # ______ WC ____________ Employee/Petitioner 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 ____________ . The only disputed issue is the nature and extent of the injury. By stipulation, the parties agree on the following items: • On ____________ , the respondent ________________________________________ was operating under and subject to the provisions of the Act. • On this date, the relationship of employee and employer did exist between the petitioner and respondent. • On this date, the petitioner sustained accidental injuries that arose out of and in the course of employment. • Timely notice of this accident was given to the respondent. • In the year preceding the injury, the petitioner earned $ _________________ , and the average weekly wage was $ ________________ . single • At the time of injury, the petitioner was _____ years of age, with _____ children under 18. • Necessary medical services have been provided by the respondent. • The respondent shall pay the petitioner temporary total disability benefits of $ ______________ /week for _______ weeks, from _______________ through _______________ , which is the period of temporary total disability for which compensation is payable. • To date, $ _______________ has been paid for TTD and/or maintenance benefits. After reviewing all of the evidence presented, the arbitrator hereby makes findings regarding the nature and extent of the injury, and attaches the findings to this document. ICArbDecN&E 6/08 100 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 ORDER • The respondent shall pay the petitioner the sum of $ ____________ /week for a further period of __________ weeks, as provided in Section _________ of the Act, because the injuries sustained caused _________________________________________________________________________________________ _________________________________________________________________________________________ • The respondent shall pay the petitioner compensation that has accrued from ____________ through ____________ and shall pay the remainder of the award, if any, in weekly payments. • The respondent shall pay $ ____________ for medical services, as provided in Section 8(a) of the Act. Unless a Petition for Review is filed within 30 days after receipt of this decision, and a review is perfected in accordance with the Act and Rules, then this decision shall be entered as the decision of the Commission. RULES REGARDING APPEALS 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. STATEMENT OF INTEREST RATE ________________________________________ ____________ Signature of arbitrator Date ICArbDecN&E p.2 American LegalNet, Inc. www.FormsWorkflow.com