ILLINOIS WORKERS COMPENSATION COMMISSION PETITION FOR AN IMMEDIATE HEARING UNDER SECTION 19(b) OF THE ACT Complete both sides of this form. _______________________________________________ Case # ________ WC ____________________ Employee/Petitioner v. _______________________________________________ Employer/Respondent I, the petitioner, request an immediate hearing in this matter. I am un able to return to work at this time because of the injuries ordisability caused by my employment, and I am not receiving temporary tot al disability benefits or medical benefits. I furtherprovide the following information: 1. Date, time, and location of accident _________________________ _________________ __________________________ Date Time Location 2. Description of accident _______________________________________________________________________ 3. Nature of injury _______________________________________________________________________ 4. Notice of the accident was given orally ___ in writing ___ to ___ _____________________ on ___________________ . 5. The employer has refused to pay proper compensation ___ medical ben efits ___ . 6. I did ___ did not ___ receive medical treatment for the accident from a medical provider selected by the employer.7. Name and address of medical provider(s), and dates of treatments: __________________________________________________________________ ________________________________________________________________________ __________________________ 8. Are any medical bills in dispute? If so, please list. ________________ _________________________________________ ________________________________________________________________________ __________________________ 9. On ____________________ , I gave the employer (list name and job title) _______________________ _________________ the following information stating I am unable to return to work: A rece nt statement, signed by a medical provider ____ Other (explain) _____________________________________________________ _______________________________ 10. When was the last payment of temporary total disability benefits, if any ? ______________________________________ 11. In an attempt to resolve the disputed matters, ________________________ _____________________________________ Petitioner or petitioners attorney (please print) conferred with _____________________________________________________ b y telephone ___ in person ___ Respondent or respondents representative on _________________________ , but they were unable to resolve this dispute. ________________________________________________________________________________ _____________________________Signature of petitioner or petitioners attorney Date Telephone number ATTENTION, RESPONDENT. According to Commission Rules, you must file a Response to the Petition for an Immediate Hearing within 15 days from the date this petition was served on you. If you f ail to respond in good faith, attorneys fees orpenalties may be levied against you. IC7 12/04 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free 866/352-3033 Web site: www.iwcc.il.govDownstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084 American LegalNet, Inc. www.USCourtForms.com>>>> 2 PROOF OF SERVICE If the person who signed the Proof of Service is not an attorney, this form must be notarized. This form must be served on the arbitrator and other parties 15 days before the status call. I, ________________________________ , affirm that I delivered _____ mailed with proper postage _____ in the city of _________________________________ a copy of this form at ___________ __________________on _ to each party at the address(es) listed below. ____________________________________________ Signature of person completing Proof of Service Signed and sworn to before me on __________________ ___________________________________________ Notary Public IC7 Page 2 American LegalNet, Inc. www.USCourtForms.com