Fillable Printable Workers' Compensation Commission Application for Ajustment Claim - Illinois

Workers' Compensation Commission Application for Ajustment Claim - Illinois

ILLINOIS WORKERS’ COMPENSATION COMMISSION

APPLICATION FOR ADJUSTMENT OF CLAIM (APPLICATION FOR BENEFITS)

ATTENTION.Please type or print. Answer all questions. File three copies of this form.

Workers' Compensation Act___ Occupational Diseases Act ___ Fatal case? No ___ Yes ___ Date of death __________

_________________________________Case #

Employee/Petitioner(Office use only)

_________________________________Location of accident ________________________

Employer/Respondentor last exposure City, State

______________________________________________________________________________________

Injured employee's name

Street addressCity, State, Zip code

______________________________________________________________________________________

Employer's nameStreet addressCity, State, Zip code

Employee information: State Employee? Yes____ No____ Male____ Female ____ Married ____ Single ____

# Dependents under age 18 ______Birthdate _____________ Average weekly wage $ _________________

Date of accident

_______________________ The employer was notified of the accident orally ____ in writing ____

How did the accident occur? ____________________________________________________________________________

What part ofthe body wasaffected?______________________________________________________________________

What is the nature of the injury? ___________________________________ Return-to-work date

________________

Is a Petition for an Immediate Hearing attached? Yes ____ No ____

Is the injured employee currently receiving temporary total disability benefits? Yes ____ No ____

If a prior application was ever filed for this employee, list the case number and its status ______________________________

ATTENTION,PETITIONER.This is a legal document. Be sure all blanks are completed correctly and you understand the statements before

you sign this. Refer to the Commission's Handbook on Workers' Compensation and Occupational Diseases

for more information.

___________________________________________________________________

Signature of petitionerDate

APPEARANCE OF PETITIONER'S ATTORNEY

Please attach a copy of the Attorney Representation Agreement.

_____________________________________________________________________________________

Signature of attorney Street address

_____________________________________________________________________________________

Attorney’s name and IC code #

(please print)City, State, Zip code

___________________________________________________________________________________

Firm nameTelephone numberE-mail address

IC1 5/12100 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

PROOF OF SERVICE

If the person who signed the Proof of Serviceis not an attorney, this form must be notarized.

If you prefer, you may submit the front of this application form with theProof of Serviceon a separate page.

I, _______________________________ , affirm that I delivered _____ mailed with proper postage _____

in the city of _________________________________ a copy of this form

at ___________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

In most cases, the injured employee files this application and is referred to as the petitioner. If the injury was fatal, orif the worker is a

minor or incapacitated, another person (as allowed by law) may file.In those cases, the person filing the application is the petitioner, and

the worker is referred to as the injured employee. Please complete information related to age, etc., for the injured employee.

This may be the date of the accident, last exposure, disability, or death.

If the employee has not returned to work, leave this space blank.

The Commission publishes a handbook that explains the workers' compensation system. If you would like a copy, please call any of the

Commission offices listed on the other side of this form.

The Commission assigns code numbers to attorneys who regularly practice before it. To obtain or look up a code number, contact the

Information Unit in Chicago or any of the downstate offices at the telephone numbers listed on this form.

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