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ILLINOIS WORKERS' COMPENSATION COMMISSION NOTICE OF CHANGE OF ADDRESS
ATTENTION. Please submit one form for each case.

_________________________________________
Employee/Petitioner

Case # ______ WC __________________

v.

_________________________________________
Employer/Respondent

Effective date _______________________

Please change your records and direct any future correspondence regarding this case to: _____________________________________
Signature of attorney

_________________________________
Street address

_____________________________________
Attorney's name and attorney code # (please print)

_________________________________
City, State, Zip code

_____________________________________
Firm name

_________________________________
Telephone number E-mail address

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 _____ mailed with proper postage _____ in the city of _________________________________ a copy of this form at ___________ AM on _________________ to the respondent listed on this application and to each additional party, if any, at the address listed below.

____________________________________________
Signature of person completing Proof of Service

Signed and sworn to before me on ________________

___________________________________________
Notary Public
IC26 9/08 100 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