worker-comp-law_W3_A3

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) v.

_________________________________ Location of accident ________________________ Employer/Respondent or last exposure City, State

______________________________________________________________________________________ Injured employee's name 1 Street address City, State, Zip code

______________________________________________________________________________________ Employer's name Street address City, State, Zip code

Employee information: Social Security # _________________ Male ____ Female ____ Married ____ Single ____

# Dependents under age 18 ______ Birthdate _____________ Average weekly wage $ ______________

Date of accident 2 _____________________ The employer was notified of the accident orally ____ in writing ____ .

How did the accident occur? ____________________________________________________________________________

What part of the body was affected? ______________________________________________________________________

What is the nature of the injury? ___________________________________ Return-to-work date 3 ________________

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 4 for more information.

_________________________________________ _____________________ Signature of petitioner Date

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 #

5 (please print) City, State, Zip code

_________________________________________ ___________________ ____________________ Firm name Telephone number E-mail address IC1 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 Disclosure of this information to the Commission is done voluntarily under 820 ILCS 305/6(b).

PROOF OF SERVICE If the person who signed the Proof of Service is not an attorney, this form must be notarized.

If you prefer, you may submit the front of this application form with the Proof of Service on 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

1 In most cases, the injured employee files this application and is referred to as the petitioner. If the injury was fatal, or if 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. 2 This may be the date of the accident, last exposure, disability, or death. 3 If the employee has not returned to work, leave this space blank. 4 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. 5 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. IC1 page 2

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