IL L INOIS WOR K ERS COM PENS ATION COM M ISSION PETITION FOR REVIEW OF AR BITRA TION DECISION UNDER SECTION 19(b-1) OF THE ACT Please file two copies of this form. ______________________________________ Case # ________ WC _______________ Employee/Petitioner v. ______________________________________ Employer/Respondent The petitioner ____ respondent ____ requests the Commission to review the arbitration decision for this case, filed on ___________________ and received on ___________________ , and to take the following steps: 1. Furnish ______ transcripts of the arbitration hearings regarding the S ection 19(b-1) petition, including all exhibits. The transcript was ___ was not ___ ordered at arbitration. I have paid $ __________ to the court reporter and enclose a copy of the check. I guarantee payment for the cost to prepare and copy the transcripts, even if I withdraw this appeal, within 30 days from the court reporters written request, and enter myself as surety therefor. 2. 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 ___ Section 19(k) employment? necessary? ___ Section 19(l) ___ Is the date correct? ___ Is prospective medical care necessary? STATUTE OF LIMITATIONS BENEFIT RATES NOTICE ___ Was the case filed within the statute ___ Are the benefit rates correct? of limitations? ___ Was the respondent given proper ___ Are the wage calculations notice? correct? TEMPORARY DISABILITY OCCUPATIONAL DISEASE ___ Is there a causal connection? EMPLOYMENT ___ Was there an exposure? ___ Is the duration of the disability ___ Was there an employer-employee correct? relationship? ___ Was there a disease? ___ Did it arise out of employment? JURISDICTION ___ Was it in the course of ___ Does the Commission have employment? jurisdiction? ___ What was the last date of exposure? I offer the following testimony or exhibits to support my petition: (Cite page/exhibit #, legal references, etc.) ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ _____________________________________________ ______________________________________ Signature Telephone number Street address _____________________________________________ ______________________________________ Name (please print; attorneys, include IC attorney code#) City, State, Zip code IC11a 12/04 100 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.USCourtForms.com>>>> 2 PROOF OF SERVICE If the person who signed the P roof of Service is not an attorney, this form must be notarized. I, _______________________ , affirm that I delivered _____ sent by certified mail (return receipt requested) _____ a copy of this form at ___________ on __________________ to each party at the address(es) listed bel ow. ____________________________________________ Signature of person completing Proof of Service Signed and sworn to before me on _________________ ______________________________________________ Notary Public IC11a page 2 American LegalNet, Inc. www.USCourtForms.com