ILLINOIS WORKERS’ COMPENSATION COMMISSION RESPONSE TO PETITION FOR AN IMMEDIATE HEARING UNDER SECTION 19(b) OF THE ACT _______________________________________________ Case # ________ WC ____________________ Employee/Petitioner v. _______________________________________________ Employer/Respondent On ____________________ , the respondent received the petitioner's Petition for an Immediate Hearing Under Section 19(b) of the Act . By law, the respondent must reply within 15 days of receipt. The respondent makes the following claims: YES NO The petitioner was an employee of the respondent on the date of the alleged accident or exposure. The alleged accident or disease arose out of and in the course of employment. ____ ____ ____ ____ The respondent indicates its agreement or disagreement with the petitioner's allegations regarding each of the following items: AGREE DISAGREE 1. Date, time, and location of the accident ____ ____ 2. Description of the accident ____ ____ 3. Nature of the injury ____ ____ 4. Notice of the accident ____ ____ 5. Employer's refusal to pay proper compensation and/or medical benefits ____ ____ 6. Treatment of employee by a medical provider selected by the employer ____ ____ 7. Medical providers and treatments ____ ____ 8. Medical bills in dispute ____ ____ 9. Employer's receipt of a statement from a medical provider indicating employee cannot work ____ ____ 10. Last payment of temporary total disability benefits ____ ____ 11. Unsuccessful effort to resolve dispute between employee and employer ____ ____ On the back of this form, please explain each area of disagreement. ______________________________________________________ Signature of respondent or respondent's attorney Date ______________________________________________________ Name (please print; attorneys, please include IC code #) IC8 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 EXPLANATION: P ROOF OF S ERVICE 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 IC8 page 2 American LegalNet, Inc. www.USCourtForms.com