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ILLINOIS WORKERS' COMPENSATION COMMISSION RESPONSE TO PETITION FOR AN IMMEDIATE HEARING UNDER SECTION 19(b) OF THE ACT

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Employee/Petitioner v.

Case # ________ WC ____________________

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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: 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: 1. 2. 3. 4. 5. 6. 7. 8. 9. Date, time, and location of the accident Description of the accident Nature of the injury Notice of the accident Employer's refusal to pay proper compensation and/or medical benefits Treatment of employee by a medical provider selected by the employer Medical providers and treatments Medical bills in dispute Employer's receipt of a statement from a medical provider indicating employee cannot work
YES NO

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AGREE

DISAGREE

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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.

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Signature of respondent or respondent's attorney Date

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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

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 ___________ AM on ___________________ to each party at the address(es) listed below.

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Signature of person completing Proof of Service

Signed and sworn to before me on __________________

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Notary Public
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