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ILLINOIS WORKERS' COMPENSATION COMMISSION INJURED WORKERS' BENEFIT FUND: REQUEST FOR BENEFITS AND AFFIDAVIT

_________________________________
Employee/Petitioner

Case # ____ WC ___________

v.

_________________________________
Employer/Respondent

I, _____________________________________________________ , duly swear:
Petitioner's name

The Injured Workers' Benefit Fund was joined with the employer as a respondent in this case. On _______________ , the Commission awarded $ ____________________ in benefits (excluding penalties and attorneys' fees). A copy of that document is attached. The employer/respondent failed to obtain workers' compensation insurance coverage for this case. I now ask the Commission to pay the benefits due from the Injured Workers' Benefit Fund. Benefits paid to date by employer $ ____________________ Unpaid benefits $ ____________________

I understand that by accepting this compensation from the Illinois Workers' Benefit Fund, I will not receive any further monetary award from the Illinois Workers' Benefit Fund for this case.

_______________________________________________________
Petitioner's signature

________________________
Date

_______________________________________________________
Petitioner's mailing address

________________________
Social Security Number (required)

Subscribed and sworn to before me on ___________________________

_________________________________ Notary Public

IC44 6/08 100 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