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ILLINOIS WORKERS' COMPENSATION COMMISSION NOTICE OF MOTION AND ORDER
ATTENTION. You must attach the motion to this notice. If the motion is not attached, this form may not be processed.

_________________________________________
Employee/Petitioner

Case # ______ WC _______________

v.

_________________________________________
Employer/Respondent

TO:

On ____________________ , at ____________ AM or as soon thereafter as possible, I shall appear before the Honorable _________________________________ , or any arbitrator or commissioner appearing in his or her place at ______________________________ , Illinois, and present the attached motion for: ___ Change of venue
(list case#) (#3072)

___ Fees under Section 16

(#1600) (#1645)

___ Reinstatement of case ___ Request for hearing

(#3074)

___ Consolidation of cases (#3071)

___ Fees under Section 16a

(#R33)

___ Hearing under Sect.19(b) (#1902) ___ Dismissal of attorney ___ Dismissal of review
(#3052)

___ Withdrawal of attorney (#3073) ___ Other (explain) __________________________

___ Penalties under Sect. 19(k) (#1911) ___ Penalties under Sect. 19(l)
(#1912)

(#3085)

______________________________________________ Signature Petitioner ____ Respondent ____ ______________________________________________ 1 Attorney's name and IC code # (please print) ______________________________________________ Name of law firm, if applicable

_______________________________________________ Street address _______________________________________________ City, State, Zip code ____________________ Telephone number _________________ E-mail address

O RDER The motion is set for hearing on ___________
____________________________________________
Signature of arbitrator or commissioner

_______________________
Date

O RDER The motion is ___ Granted ___ Denied ___ Withdrawn ___ Dismissed ___ Continued to ________________ ___ Set for trial (date certain) on ________________
_______________________
Date

____________________________________________
Signature of arbitrator or commissioner

IC4 12/04 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free line 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

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 ___________
AM

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

1

The Workers' Compensation Commission assigns code numbers to attorneys who regularly practice before it. To obtain or look up a code number, contact the Information Unit in Chicago or any of the downstate offices at the telephone numbers listed on this form.
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