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ILLINOIS WORKERS' COMPENSATION COMMISSION NOTICE OF REJECTION OF SETTLEMENT CONTRACT

_____________________________________________
Employee/Petitioner

Case # ______ WC __________________

v. _____________________________________________
Employer/Respondent

This settlement contract was presented to me on the following reason:

____________________________ .

I am rejecting it for

The parties have ____ have not ____ been advised that, after assignment by the Review Unit, they may have the rejected contract reviewed by a commissioner, who may approve or reject the contract.

______________________________________
Signature of arbitrator

___________________________
Date

ARBITRATOR: if you reject a contract, please attach this form to the contract. ATTORNEY: if you wish to have the rejected contract reviewed by a commissioner, please bring it to the Vault. COMMISSIONER : if you reject this contract, please return it to the Vault. The case will be returned to the call.

IC32 3/06 100 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