Free IC23 - Illinois

ILLINOIS WORKERS' COMPENSATION COMMISSION PETITION TO REINSTATE CASE
ATTENTION: This petition must be filed within 60 days of receipt of the dismissal order.

_______________________________________________
Employee/Petitioner v.

Case # ________ WC ____________________

_______________________________________________
Employer/Respondent

On _____________________ , this case was dismissed for want of prosecution. I received the dismissal order on
_____________________ . On _____________________ , I will present this petition to reinstate the case before

Arbitrator ______________________________________ for the following reason:

___________________________________________________ Signature

___________________________________________________ Name (please print; attorneys, please include IC code number)

_________________________________________________ Telephone number

_________________________ Date

IC23 12/04 100 W. Randolph St. #8-200 Chicago, IL 60601 312/814-611

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