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ILLINOIS WORKERS' COMPENSATION COMMISSION ARBITRATION CASE INFORMATION SHEET
ATTENTION. Please complete this form, have both parties sign it, and place it in the arbitrator's message box next to the hearing room door or other area designated by the arbitrator. Do not interrupt the hearings. Be as specific as possible.

You must see the arbitrator if your case is above the red line.
Arbitrator ______________________________________ Case # ________ WC ____________________________
v.

_____________________________________________ Employee/Petitioner

Today's date ____________________________________
_____________________________________________ Employer/Respondent

Status call date and line # ________________________

Please check the appropriate box.

Petitioner is receiving TTD. Petitioner is still treating.
Name of doctor/clinic: ____________________________________________________ Date and nature of last treatment: ___________________________________________________________________

Petitioner is receiving vocational rehabilitation/job placement services.
Date and nature of last service: ______________________________________________________________________

Deposition scheduled for

____________________

We expect to be ready for trial by ____________________

Tentative settlement reached.

We will submit contract for approval by ____________________
____________________

Request for approval of Medicare set-aside was submitted on The case will be ready for trial by The case was partially tried on Other
____________________

____________________

Next trial date is ____________________

(explain) ____________________________________________________________________________________

____________________________________________________________________________________________________

_______________________________________________
Signature of petitioner's attorney

___________________________________________
Signature of respondent's attorney

_______________________________________________
Name of petitioner's attorney (please print)

___________________________________________
Name of respondent's attorney (please print)

IC41 6/05 100 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