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ILLINOIS WORKERS' COMPENSATION COMMISSION REQUEST FOR HEARING
ATTENTION. Please give this form to the arbitrator after you obtain a trial date.

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Employee/Petitioner

Case # ______ WC __________________

v.

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Employer/Respondent

Setting __________________________

The petitioner and respondent are prepared to try this matter to completion on __________________ , unless the arbitrator approves other arrangements. 1. Petitioner claims that, on __________________ , the petitioner and respondent were operating under the Illinois Workers' Compensation or Occupational Diseases Act, and their relationship was one of employee and employer. Respondent agrees ____ disputes ____ for the following reason: _____________________________________ .

2. Petitioner claims that, on the above date, he or she sustained accidental injuries or was last exposed to an occupational disease that arose out of and in the course of employment. Respondent agrees ____ disputes ____ for the following reason: _____________________________________ .

3. Petitioner claims his or her condition of ill-being is causally connected to this injury or exposure. Respondent agrees ____ disputes ____ for the following reason: _____________________________________ .

4. Petitioner claims that the respondent was given notice of the accident within the time limits stated in the Act. Respondent agrees ____ disputes ____ . If in dispute, the petitioner states that on __________________ , notice was given to _______________________________ , with the job title _____________________________ . 5. Petitioner claims his or her earnings during the year preceding the injury were $ _______________, and the average weekly wage, calculated pursuant to Section 10 of the Act, was $ __________________ . Respondent agrees ____ disputes ____ . The respondent claims the earnings in the year preceding the injury were $ _______________ , and the average weekly wage was $ __________________ . 6. At the time of injury, the petitioner was ___ years old; married ____ single ____ ; with ____ children under 18 years old. Respondent agrees ____
Attach a list, if necessary.

disputes ____ for the following reason: _______________________________________ .

7. Petitioner claims Respondent is liable for the following unpaid medical bills (list): Respondent agrees ___ disputes ___ .

Respondent claims it paid $ __________________ of the above bills through its group medical plan for which credit may be allowed under Section 8(j) of the Act.
IC9 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

8. Petitioner claims he or she was temporarily totally disabled from __________________ through __________________ , representing ____ weeks.
First day of lost time Last day of lost time

Respondent agrees ____ . Respondent agrees to the TTD period, but denies liability. ____ . Respondent disputes ____ . Respondent claims the petitioner was disabled from __________________ through __________________ , representing ____ weeks. 9.
First day of lost time Last day of lost time

Respondent claims it paid $ __________________ in TTD and/or maintenance benefits. Petitioner agrees ____ disputes ____ . Petitioner claims $ __________________ was paid.

Respondent claims it paid $ __________________ in group, nonoccupational disability benefits for which credit may be allowed under Section 8(j) of the Act. Petitioner agrees ____ disputes ____ . Petitioner claims $ __________________ was paid. 19(l) ____ , and/or attorneys'

10. Petitioner claims to be entitled to additional compensation under Section 19(k) ____ fees under Section 16 ____ of the Act. Petitioner has ____ 11. The nature and extent of the injury is ____

has not ____ filed a penalty petition.

is not ____ in dispute. Additional issues are:

12. A petition for attorneys' fees by a former attorney is ____ the former attorney of the date of this hearing.

is not ____ pending. Petitioner's attorney has notified

13. Petitioner will submit any depositions by __________________ . Respondent will submit any depositions by __________________ . 14. STENOGRAPHIC STIPULATION. Both parties agree that if either party files a Petition for Review of Arbitration Decision and orders a transcript of the hearings, and if the Commission's court reporter does not furnish the transcript within the time limit set by law, the other party will not claim the Commission lacks jurisdiction to review the arbitration decision because the transcript was not filed timely.
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Date submitted

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Name of respondent's insurance or service company (please print)

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Signature of petitioner or petitioner's attorney

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Signature of respondent or respondent's attorney

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Attorney's name and IC code # (please print)

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Attorney's name and IC code # (please print)

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Name of law firm

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Name of law firm

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Street address

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Street address

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City, State, Zip code

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City, State, Zip code

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Telephone number

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Telephone number

N OTE: The arbitration decision will be sent by certified mail to the addresses listed above. IC9 page 2