ILLINOIS WORKERS' COMPENSATION COMMISSION REQUEST FOR HEARING ATTENTION. Please give this form to the Arbitrator after you obtain a trial date. Case # ______ WC _______________ ______________________________________ Employee/Petitioner Consolidated cases: _________________________ Setting _____________________________________ v. ______________________________________ Employer/Respondent Petitioner and Respondent are prepared to try this matter to completion on ____________________ , unless the Arbitrator approves other arrangements. 1. Petitioner claims that, on ____________________ , Petitioner and Respondent were operating under the Illinois Workers' Compensation or Occupational Diseases Act, and their relationship was one of employee and employer. Respondent agrees ____ disputes ____ . 2. Petitioner claims that, on the above date, he or she sustained accidental injuries or was last exposed to an occupational disease that arose out of and in the course of employment. Respondent agrees ____ disputes ____ . 3. Petitioner claims Respondent was given notice of the accident within the time limits stated in the Act. Respondent agrees ____ disputes ____ . If in dispute, Petitioner states that on _____________________ , notice was given to _____________________________ , with the job title _______________________________ . 4. Petitioner claims his or her current condition of ill-being is causally connected to this injury or exposure. Respondent agrees ____ disputes ____ . 5. Petitioner claims his or her earnings during the year preceding the injury were $ __________________, and the average weekly wage, calculated pursuant to Section 10 of the Act, was $ __________________. Respondent agrees ____ disputes ____ and claims _________________________________________________ 6. At the time of injury, Petitioner was ___ years old; married ___ single ___ ; with ___ dependent children. Respondent agrees ____ disputes ____ and claims _________________________________________________ 7. Petitioner claims Respondent is liable for the following unpaid medical bills: Attach a list, if necessary. Respondent agrees ____ disputes ____ and claims _________________________________________________ Respondent claims it paid $ __________________ in medical bills through its group medical plan for which credit may be allowed under Section 8(j) of the Act. Petitioner agrees ____ disputes ____ and claims ___________________________________________________ IC9 2/10 100 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.FormsWorkFlow.com 8. Petitioner claims to be entitled to (Attach a sheet if necessary to list additional periods.) TTD period(s): ______________________________________________________ , representing _______ weeks. First day of lost time through Last day of lost time Respondent agrees ____ disputes ____ and claims _______________________________________________ TPD period(s): ________________________________________________________ , representing _______ weeks. First day through Last day Respondent agrees ____ disputes ____ and claims _______________________________________________ Maintenance period(s): _________________________________________________ , representing _______ weeks. First day through Last day Respondent agrees ____ disputes ____ and claims _______________________________________________ 9. Respondent claims it paid $ __________________ in TTD, $ __________________ in TPD, $ _________________ in maintenance, $ _________________ in nonoccupational indemnity disability benefits, and $ __________________ in other benefits, for which credit may be allowed under §8(j) of the Act. Petitioner agrees ____ disputes ____ and claims ___________________________________________________ 10. The nature and extent of the injury is ____ is not ____ in dispute. 11. Petitioner claims to be entitled to penalties/attorney's fees under §19(k) ___ §19(l) ___ and/or §16 ___. Petitioner has ____ has not ____ filed a penalty petition. 12. A petition for attorney's fees by a former attorney is ____ is not ____ pending. Petitioner's attorney has notified the former attorney of the date of this hearing. 13. Other issues, not listed above, are: ______________________________________________________________________ 14. STENOGRAPHIC STIPULATION. Both parties agree that if either party files a Petition for Review of Arbitration Decision and orders a transcript of the hearings, and if the Commission's court reporter does not furnish the transcript within the time limit set by law, the other party will not claim the Commission lacks jurisdiction to review the arbitration decision because the transcript was not filed timely. A written decision, including findings of fact and conclusions of law, is requested pursuant to Section 19(b). __________________________________________________ Date submitted ________________________________________________ Name of Respondent's insurance or service company __________________________________________________ Signature of Petitioner or Petitioner's attorney ________________________________________________ Signature of Respondent or Respondent's attorney __________________________________________________ Attorney's name and IC code # ________________________________________________ Attorney's name and IC code # __________________________________________________ Name of law firm ________________________________________________ Name of law firm __________________________________________________ Street address ________________________________________________ Street address __________________________________________________ City, State, Zip code ________________________________________________ City, State, Zip code ______________________ ___________________________ Telephone number Email address _____________________ _________________________ Telephone number Email address NOTE: The arbitration decision will be sent by certified mail to the addresses listed above. 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