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ILLINOIS WORKERS' COMPENSATION COMMISSION PETITION FOR REVIEW OF ARBITRATION DECISION
To appeal an arbitration decision, file two copies of this form within 30 days of receipt of the decision.

______________________________________
Employee/Petitioner v.

Case # ________ WC _______________

______________________________________
Employer/Respondent

The petitioner ____ respondent ____ requests the Commission to review the arbitration decision for this case, filed on _______________ and received on _______________ , and to take the following steps: 1. Furnish a transcript of the arbitration hearings, including all exhibits, to be presented to the Commission. I guarantee to pay for the cost to prepare the transcript within 30 days from the court reporter's written request, even if I later withdraw this appeal, and enter myself as surety therefor. Note: The first party to file a petition will be charged for the cost to prepare the transcript (original rate). Provide ____ copy/copies of the transcript. I similarly guarantee payment at the copy rate. 2. Extend the time allowed to file the transcript or the agreed statement of facts by 30 days past the time allowed by statute or stipulation. 3. Consider the issues checked below to which I take exception:
ACCIDENT ___ Did it occur? ___ Did it arise out of employment? ___ Was it in the course of employment? ___ Is the date correct? BENEFIT RATES ___ Are the benefit rates correct? ___ Are the wage calculations correct? EMPLOYMENT ___ Was there an employer-employee relationship? JURISDICTION ___ Does the Commission have jurisdiction? MEDICAL EXPENSES ___ Is there a causal connection? ___ Is the charge reasonable? ___ Was the treatment reasonably necessary? ___ Is prospective medical care necessary? NOTICE ___ Was the respondent given proper notice? OCCUPATIONAL DISEASE ___ Was there an exposure? ___ Was there a disease? ___ Did it arise out of employment? ___ Was it in the course of employment? ___ What was the last date of exposure? OTHER (explain) ________________ PENALTIES AND FEES ___ Section 16 ___ Section 19(k) ___ Section 19(l) PERMANENT DISABILITY ___ Is there a causal connection? ___ What is the nature and extent of the disability? STATUTE OF LIMITATIONS ___ Was the case filed within the statute of limitations? TEMPORARY DISABILITY ___ Is there a causal connection? ___ Is the duration of the disability correct?

4. Oral argument: Requested ___ Waived ___

_________________________________________________ Signature Telephone number _________________________________________________ Name (please print; attorneys, please include IC attorney code #)

______________________________________________ Street address ______________________________________________ City, State, Zip code

IC11 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.

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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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