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ILLINOIS WORKERS' COMPENSATION COMMISSION PETITION FOR REVIEW UNDER SECTION 19(h) OR 8(a) OF THE ACT
Please file two copies of this form. _____________________________________________
Employee/Petitioner

Case # ______ WC __________________

v. _____________________________________________
Employer/Respondent

Today, ______________ , the petitioner ___ this case under Section 19(h) 1 ___

respondent ___ petitions the Commission to review

Section 8(a) 2 ___ of the Act.

I also ask the Commission to furnish ______ transcripts of the arbitration hearings, including all exhibits. I guarantee payment for the cost to prepare and copy the transcripts, even if I later withdraw this petition, within 30 days from the court reporter's written request, and enter myself as surety therefor.
_____________________________________________
Signature

_____________________________________________
Street address

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

_____________________________________________
City, State, Zip code

_____________________________________________
Telephone number

_____________________________________________
Transcript due date

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 ______ in the city of ________________________ a copy of this form at ______________ AM

mailed with proper postage ______

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 Section 19(h) of the Act provides that if the injured employee's disability has materially changed within 30 months after the decision or settlement contract (if

it provides for installment payments, rather than a lump sum payment), either party may request a review by the Commission.
2 Section 8(a) of the Act provides for a review by the Commission if additional medical expenses are incurred. IC14 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