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ILLINOIS WORKERS' COMPENSATION COMMISSION REQUEST FOR VOLUNTARY ARBITRATION

_____________________________________________
Employee/Petitioner

Case # ______ WC ___________________

v. _____________________________________________
Employer/Respondent

Voluntary Arbitration Case # _________________

The petitioner and respondent request the Commission to assign this case to voluntary arbitration under

____ Section 19(p) of the Workers' Compensation Act

____ Section 19(m) of the Occupational Diseases Act

The parties understand that, by submitting to voluntary arbitration, they are giving up certain rights. They stipulate the only issue in dispute is

____ Temporary Total Disability

____ Permanent Partial Disability

____ Medical expenses

The parties understand they may select from a list of designated Commission arbitrators or they may submit the case to the American Arbitration Association. The parties choose _____________________________________________ to hear this matter.
___________________________________________________
Signature of petitioner Date

___________________________________________________
Signature of respondent Date

___________________________________________________
Signature of petitioner's attorney Date

___________________________________________________
Signature of respondent's attorney Date

___________________________________________________
Name of petitioner's attorney and IC code #(please print)

___________________________________________________
Name of respondent's attorney and IC code # (please print)

O PTION TO P ROCEED W ITHOUT AN A TTORNEY Voluntary arbitration under Section 19(p) or Section 19(m) requires an understanding of the Workers' Compensation Act or Workers' Occupational Diseases Act as well as the laws of evidence and trial procedure. You are entitled to be represented by an attorney if you so desire. The arbitrator's decision under this procedure is conclusive on all findings of fact and your rights to appeal to the Courts are strictly limited to questions of law. Before beginning the trial, the arbitrator read and discussed the above paragraph with the petitioner, who has chosen to proceed without an attorney. This election is confirmed by the signatures below.

___________________________________________________
Signature of arbitrator

____________________________
Date

___________________________________________________
Signature of petitioner

___________________________________________________
Signature of respondent

IC36 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