ILLINOIS WORKERS COMPENSATION COMMISSION PETITION FOR REVIEW UNDER SECTION 19(h) OR 8(a) OF THE ACT Please file two copies of this form. _____________________________________________ Case # ______ WC __________________ Employee/Petitioner v. _____________________________________________ Employer/Respondent Today, ______________ , the petitioner ___ respondent ___ petitions the Commission to review 1 2 this case under Section 19(h) ___ Section 8(a) ___ of the Act. I also ask the Commission to furnish ______ transcripts of the arbitration hearings, including all exhibits. I gu arantee paymentfor the cost to prepare and copy the transcripts, even if I later withdr aw this petition, within 30 days from the court reporterswritten request, and enter myself as surety therefor. _____________________________________________ _____________________________________________ Signature Street address _____________________________________________ _____________________________________________ Name (please print; attorneys, include IC code #) City, State, Zip code _____________________________________________ _____________________________________________ Telephone number Transcript due date 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 1 Section 19(h) of the Act provides that if the injured employees disability has materially changed within 30 months after the decision or settlement contract (ifit provides for installment payments, rather than a lump sum payment), either party may request a review by the Commission. 2 Section 8(a) of the Act provides for a review by the Commission if additional medical expenses are incurred. IC14 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