ILLINOIS WORKERS COMPENSATION COMMISSION PETITION FOR REVIEW OF ARBITRATION DECISION To appeal an arbitration decision, file two copies of this form within 30 days of receipt of the decision.______________________________________ Case # ________ WC _______________ Employee/Petitioner v. ______________________________________ Employer/Respondent The petitioner ____ respondent ____ requests the Commission to revie w the arbitration decision for this case, filed on _______________ and received on _______________ , and to ta ke the following steps: 1. Furnish a transcript of the arbitration hearings, including all exhibits , to be presented to the Commission. I guarantee to pay for the cost to prepare the transcript within 30 days from the court reporters written request, even if I later withdraw this appeal, and enter myself as surety therefor. Note: The first party to file a petition will be charged for the cost to prepare the transcript (original rate). Provide ____ copy/copies of the transcript. I similarly guarantee pay ment at the copy rate. 2. Extend the time allowed to file the transcript or the agreed statement o f facts by 30 days past the time allowed by statute or stipulation. 3. Consider the issues checked below to which I take exception: ACCIDENT MEDICAL EXPENSES OTHER (explain) ________________ ___ Did it occur? ___ Is there a causal connection? PENALTIES AND FEES ___ Did it arise out of employment? ___ Is the charge reasonable? ___ Section 16 ___ Was it in the course of ___ Was the treatment reasonably employment? necessary? ___ Section 19(k) ___ Is the date correct? ___ Is prospective medical care ___ Section 19(l) necessary? BENEFIT RATES PERMANENT DISABILITY ___ Are the benefit rates correct? NOTICE ___ Is there a causal connection? ___ Are the wage calculations ___ Was the respondent given proper ___ What is the nature and extent of the notice? disability? correct? EMPLOYMENT OCCUPATIONAL DISEASE STATUTE OF LIMITATIONS ___ Was there an employer-employee ___ Was there an exposure? ___ Was the case filed within the statute of limitations? relationship? ___ Was there a disease? JURISDICTION ___ Did it arise out of employment? TEMPORARY DISABILITY ___ Does the Commission have ___ Was it in the course of ___ Is there a causal connection? employment? jurisdiction? ___ Is the duration of the disability ___ What was the last date of exposure? correct? 4. Oral argument: Requested ___ Waived ___ _________________________________________________ ______________________________________________Signature Telephone number Street address _________________________________________________ ______________________________________________Name (please print; attorneys, please include IC attorney code #) City, State, Zip code IC11 12/04 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free line 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. 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 IC11 page 2 American LegalNet, Inc. www.USCourtForms.com