ILLINOIS WORKERS COMPENSATION COMMISSION RESPONSE TO PETITION FOR IMMEDIATE HEARING UNDER SECTION 19(b-1) OF THE ACT _________________________________ Case # ______ WC _______________ Employee/Petitioner v. _________________________________ Employer/Respondent On _______________ , the respondent received the petitioners Petition for an Immediate Hearing Under Section 19(b-1) of the Act . By law, the respondent must reply within 15 days of receipt. The re spondent makes the following claims: Y ES N O The respondent was operating under the Act on the date of the alleged ac cident. ____ ____The petitioner was an employee of the respondent on the date of the alle ged accident or exposure.____ ____The alleged accident or disease arose out of and in the course of employ ment. ____ ____The respondent indicates its agreement or disagreement with the petition ers allegations regarding each of the following items: A GREE D ISAGREE 1. Date, time, and location of the accident ____ ____2. Description of the accident ____ ____3. Nature of the injury ____ ____4. Notice of the accident ____ ____5. Employers refusal to pay proper compensation and/or medical benefits, a s claimed by petitioner____ ____6. Temporary Total Disability benefits ____ ____7. The petitioner was treated by a medical provider selected by the employe r. ____ ____8. The respondent received a list of medical providers and dates of treatme nts. ____ ____9. The parties tried but were unable to resolve this dispute. ____ ____10. The respondent received the names and addresses of employees witnesses and others testifying.____ ____11. The respondent received a recent medical report stating the employee is unable to work.____ ____12. The respondent received authorization to review the employees related m edical records.____ ____13. The respondent received documents supporting the employees allegations. ____ ____14. The respondent received a list of documents demanded by the employees s ubpoena.____ ____ATTENTION, RESPONDENT. You must submit the following items with this response: 15. Complete copies of all documents in the employers possession that you w ill use to support this response; 16. A list of all documents you are demanding by subpoena; 17. A list of the names and addresses of witnesses and others you will use t o support this response; 18. A list of the name and address of each medical provider selected by the employer to examine the employee pursuant to Section 12 of the Act, and the time and place of each exam. IC14b 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>>>> 2Explain each item of disagreement (include legal and factual issues): _______________________________________________ ___________________________________________________ Signature of person completing form Date Street address _______________________________________________ ___________________________________________________ Name (please print; attorneys, please include IC attorney code #) City, State, Zip code 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 _____ sen t by certified mail (return receipt requested) _____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 IC14b page 2 American LegalNet, Inc. www.USCourtForms.com