ILLINOIS WORKERS' COMPENSATION COMMISSION STIPULATION TO SUBSTITUTE ATTORNEYS ATTENTION, PETITIONER: please attach a copy of the Attorney Representation Agreement. _____________________________________________ Employee/Petitioner Case # ______ WC __________________ v. _____________________________________________ Employer/Respondent I, __________________________________ , want the attorney, _________________________________ , to appear on my behalf in this case. __________________________________________ Signature of petitioner or respondent I hereby withdraw as the attorney for the above party. __________________________________________ Signature of attorney __________________________________________ Name of attorney and IC attorney code # (please print) __________________________________________ Name of law firm I hereby enter my appearance as the attorney for the above party. __________________________________________ Signature of attorney __________________________________________ Name of attorney and IC attorney code # (please print) __________________________________________ Street address __________________________________________ City, State, Zip code __________________ ______________________ Telephone number Email address _________________________________________ Date IC29 8/12 100 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