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ILLINOIS WORKERS' COMPENSATION COMMISSION PETITION FOR REVIEW OF ARBITRATION DECISION UNDER SECTION 19(b-1) OF THE ACT
Please file two copies of this form.

______________________________________
Employee/Petitioner

Case # ________ WC _______________

v.

______________________________________
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 ______ transcripts of the arbitration hearings regarding the Section 19(b-1) petition, including all exhibits. The transcript was ___ was not ___ ordered at arbitration. I have paid $ __________ to the court reporter and enclose a copy of the check. I guarantee payment for the cost to prepare and copy the transcripts, even if I withdraw this appeal, within 30 days from the court reporter's written request, and enter myself as surety therefor. 2. Consider the issues checked below to which I take exception:
ACCIDENT MEDICAL EXPENSES OTHER (explain) ________________ PENALTIES AND FEES

___ Did it occur? ___ Did it arise out of employment? ___ Was it in the course of
employment?

___ Is there a causal connection? ___ Is the charge reasonable? ___ Was the treatment reasonably
necessary?

___ Section 16 ___ Section 19(k) ___ Section 19(l)
STATUTE OF LIMITATIONS

___ Is the date correct?
BENEFIT RATES

___ Is prospective medical care
necessary? NOTICE

___ Are the benefit rates correct? ___ Are the wage calculations
correct? EMPLOYMENT

___ Was the case filed within the statute
of limitations? TEMPORARY DISABILITY

___ Was the respondent given proper
notice? OCCUPATIONAL DISEASE

___ Is there a causal connection? ___ Is the duration of the disability
correct?

___ Was there an employer-employee
relationship? JURISDICTION

___ Was there an exposure? ___ Was there a disease? ___ Did it arise out of employment? ___ Was it in the course of
employment?

___ Does the Commission have
jurisdiction?

___ What was the last date of exposure? I offer the following testimony or exhibits to support my petition: (Cite page/exhibit #, legal references, etc.) ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ _____________________________________________
Signature Telephone number

______________________________________
Street address

_____________________________________________
Name (please print; attorneys, include IC attorney code#)

______________________________________
City, State, Zip code

IC11a 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

PROOF OF SERVICE
If the person who signed the Proof of Service is not an attorney, this form must be notarized.

I, _______________________ , affirm that I delivered _____ a copy of this form at ___________
AM

sent by certified mail (return receipt requested) _____

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

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