ILLINOIS WORKERS’ COMPENSATION COMMISSION NOTICE OF CHANGE OF ADDRESS ATTENTION. Please submit one form for each case. _________________________________________ Case # ______ WC __________________ Employee/Petitioner v. _________________________________________ Effective date _______________________ Employer/Respondent Please change your records and direct any future correspondence regarding this case to: _____________________________________ _________________________________ Signature of attorney Street address _____________________________________ _________________________________ Attorney’s name and attorney code # (please print) City, State, Zip code _____________________________________ _________________________________ Firm name Telephone number E-mail address 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 ___________ AM on _________________ to the respondent listed on this application and to each additional party, if any, at the address listed below. ____________________________________________ Signature of person completing Proof of Service Signed and sworn to before me on ________________ ___________________________________________ Notary Public IC26 9/08 100 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