ILLINOIS WORKERS COMPENSATION COMMISSION PETITION FOR IMMEDIATE HEARING UNDER SECTION 19(b-1) OF THE ACT ATTENTION. Complete both sides of this form. The petitioner must certify the respondent received this petition and attachments 15 days before it is filed with the Commission._____________________________________________ 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 to ___________________________________ _______________________________ orally ___ in writing ___ on ___________________ . 5. The employer has refused to pay proper compensation ___ medical benefi ts ___ . 6. When was the last payment of Temporary Total Disability benefits, if any ? ___________________________________ 7. I did ___ did not ___ receive medical treatment for the accident fr om a medical provider selected by the employer. 8. Name and address of medical provider(s), and dates of treatments: _______________________________________________________________ ________________________________________________________________________ _______________________ ________________________________________________________________________ _______________________ ________________________________________________________________________ _______________________ 9. In an attempt to obtain compensation and/or medical benefits, _________ ____________________________________ Petitioner or petitioners attorney conferred with __________________________________________________ by t elephone ___ in person ____ Respondent or respondents representative on ________________________ , but they were unable to resolve this dispute. Date IC14a 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>>>> 210. Name and address of each witness to the accident, and any other person w ho will support the employees allegations: ATTENTION, PETITIONER. You must submit the following items with this petition: 11. A recent statement, signed by a medical provider, that you are unable to return to work because of the accident, and such other documents that show you are entitled to benefits: a) your history of the accident; b) a description of the injury and medical diagnosis; c) the medical services you have received and are now receiving; d) the physical activities you cannot currently perform because of thi s injury; and e) the prognosis for recovery. 12. A signed authorization for the employer to review all related medical re cords; 13. Complete copies of any documents in your possession that will support yo ur allegations, provided the employer pays reasonable copying costs; and 14. A list of all documents you have demanded by subpoena that will support your allegations. _______________________________________________ ______________________________________________________ Signature of petitioner or petitioners attorney Date Name (please print; attorneys, please include IC attorney code #)_______________________________________________ _______________________________________________________ Street address Telephone number ______________________________________________ City, State, Zip code ATTENTION, RESPONDENT. Send this petition to your insurance carrier or claims office immedia tely. According to Commission Rules, you must file a Response to the Petition for an Immediate Hearing within 15 days from the date you received notice thatthis petition was filed with the Commission. If you fail to respond, yo u will not be able to introduce evidence in defense of thisclaim. 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 _____ sen t by certified mail (return receipt requested) _____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 IC14a Page 2 American LegalNet, Inc. www.USCourtForms.com