ILLINOIS WORKERS COMPENSATION COMMISSION REQUEST FOR VOLUNTARY ARBITRATION _____________________________________________ Case # ______ WC ___________________ Employee/Petitioner v. _____________________________________________ Voluntary Arbitration Case # _________________ Employer/Respondent The petitioner and respondent request the Commission to assign this case to voluntary arbitration under ____ Section 19(p) of the Workers Compensation Act ____ Section 19(m) of the Occupational Diseases Act The parties understand that, by submitting to voluntary arbitration, the y are giving up certain rights. They stipulate the onlyissue in dispute is ____ Temporary Total Disability ____ Permanent Partial Disability ____ Medical expenses The parties understand they may select from a list of designated Commiss ion arbitrators or they may submit the case to the American Arbitration Association. The parties choose _____________ ________________________________ to hear this matter. ___________________________________________________ ___________________________________________________ Signature of petitioner Date Signature of respondent Date___________________________________________________ ___________________________________________________ Signature of petitioners attorney Date Signature of respondents attorney Date___________________________________________________ ___________________________________________________ Name of petitioners attorney and IC code #(please print) Name of respondents attorney and IC code # (please print) OPTION TO PROCEED WITHOUT AN ATTORNEY Voluntary arbitration under Section 19(p) or Section 19(m) requires an understanding of the Workers Compensation Act or Workers Occupational Diseases Act as well as the laws of evidence and t rial procedure. You are entitled to be represented by anattorney if you so desire. The arbitrators decision under this procedu re is conclusive on all findings of fact and your rights toappeal to the Courts are strictly limited to questions of law. Before beginning the trial, the arbitrator read and discussed the above paragraph with the petitioner, who has chosen to proceedwithout an attorney. This election is confirmed by the signatures below . ___________________________________________________ ____________________________ Signature of arbitrator Date ___________________________________________________ ___________________________________________________ Signature of petitioner Signature of respondent IC36 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