Free Adobe PDF - Illinois

ILLINOIS WORKERS' COMPENSATION COMMISSION PROOF OF SERVICE
ATTENTION. If the person who signed the Proof of Service is not an attorney, this form must be notarized. Service for documents related to Section 19(b-1) of the Workers' Compensation Act must be made by personal service or certified mail.

I, ___________________________________________________ , affirm that I _____ mailed a copy of this form with proper postage in the city of __________________ _____ sent a copy of this form by certified mail (return receipt requested) _____ delivered a copy of this form at _____________ AM on _____________________ to each party at the address listed below.

__________________________________________________
Signature of person completing Proof of Service

Signed and sworn to before me _____________________

_________________________________________________
Notary Public

IC15 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