STATE OF ILLINOIS ) ) COUNTY OF ______________) ILLINOIS WORKERS COMPENSATION COMMISSION ORDER TO DISMISS OR WITHDRAW PETITION UNDER SECTION 19(b-1) OF THE ACT ____________________________________________ Case # ________ WC ____________________ Employee/Petitioner v. ____________________________________________ Setting ____________________________ Employer/Respondent On ______________________ , this case was set for a trial ____ pretrial ____ under Section 1 9(b-1) of the Act in the city of ________________________________ , Illinois. I hereby order the following: ____ The petition is dismissed for the following reasons: __________________ _____________________ ________________________________________________________________________ _________ ____ The petition is withdrawn, in response to the petitioners request. A record of the hearing was ____ was not ____ made. This order shall not be a bar to any further hearings on this case or an y subsequent petitions under Section 19(b) or 19(b-1) of the Act. Unless the parties appeal this order within 30 days of its receipt and p erfect the review in accordance with the Act and Rules, this order will be entered as the decision of the Commission. If the petition was withdrawn, or if the parties agreebelow, the order may not be appealed. If this order is appealed, and the order is not affirmed by the Commissi on, the time limit provided by law for filing the final decision shall be tolled until the Commission issues its decision. _______________________________________________ ____________________________ Signature of arbitrator Date STIPULATION ____ The parties agree this order should be entered. ____ The parties agree that the petitioner may refile the Petition for an Immediate Hearing at the arbitrators status or trial date on __________________________ , as long as the petitioner gives the respondent some prior notice. The parties do not need to refile or re-serve any of the original docume nts that were attached to the original petition. _______________________________________________ _____________________________________________ Signature of petitioner or petitioners attorney Signature of respondent or respondents attorney _______________________________________________ _____________________________________________ Name of petitioner or petitioners attorney (please print) Name of respondent or respondents attorney (please print)IC14d 12/04 100 W. Randolph St. #8-200 Chicago, IL 60601 312/814-611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Ro ckford 815/987-7292 Springfield 217/785-7084 American LegalNet, Inc. www.USCourtForms.com